Selegiline Transdermal (Emsam)

What it treats

Selegiline transdermal is approved by the U.S. Food and Drug Administration to treat major depressive disorder.

Off-label uses include some atypical and treatment-resistant depression presentations. Off-label means a purpose the label doesn't formally list even though evidence and practice support it. Oral selegiline, at lower doses, is used for Parkinson's disease; that formulation isn't the focus of this page.

How it works

Selegiline blocks monoamine oxidase, or MAO. At low oral doses it prefers MAO-B (which mainly breaks down dopamine). At higher doses, and reliably when delivered through skin, it also blocks MAO-A (which breaks down serotonin, norepinephrine, and dietary tyramine).

The clever design of the patch is that it delivers enough drug to the brain to block MAO-A there without passing through the gut in the way an oral dose would. At 6 mg per 24 hours, gut MAO-A stays intact enough that tyramine from food gets neutralized normally, so a special diet isn't needed. At 9 and 12 mg per 24 hours, more drug spills into gut MAO-A territory, and the standard MAOI diet applies.

Receptor mechanism (detail)

Selegiline is an irreversible MAO inhibitor, selective for MAO-B at low oral doses and non-selective at higher exposures. The transdermal route reaches brain MAO-A while sparing much of the gut MAO-A at 6 mg per 24 hours. At 9 and 12 mg per 24 hours, gut MAO-A inhibition rises enough that dietary tyramine can pose a risk, and the diet applies. Because the enzyme block is irreversible, restrictions persist for 14 days after stopping.

Potency and typical dosing pattern

Ranges are typical framework only, not a prescription for any individual.

Starting is 6 mg per 24 hour patch, applied to clean, dry, intact skin (upper torso, upper thigh, or outer upper arm), rotated daily. Usual range is 6 to 12 mg per 24 hours. Doses above 6 mg require the tyramine diet.

Safety monitoring

• Blood pressure at every visit. Orthostatic hypotension is possible.
• Tyramine-restricted diet at 9 mg and 12 mg patches. Not required at 6 mg.
• 14-day washout before starting most other antidepressants and 14 days after stopping selegiline transdermal before starting them. For fluoxetine specifically, wait 5 weeks after stopping it before starting selegiline transdermal.
• Avoid serotonergic drugs during and for 14 days after: SSRIs, SNRIs, tramadol, meperidine, dextromethorphan, triptans, linezolid, methylene blue, St. John's wort, MDMA. These rules apply at all patch strengths, including 6 mg.
• Application site reactions (redness, itching) are common; site rotation helps.
• Suicidality in the first 4 weeks, especially under age 25 (FDA boxed warning).

What to expect

Common side effects

Common side effects include:

• Application site reactions.
• Insomnia or vivid dreams.
• Dizziness on standing.
• Headache.
• Dry mouth.
• Diarrhea (mild).

If a side effect is severe, or it isn't improving, that's a conversation to have with the prescriber rather than a reason to stop on your own.

Serious side effects and warnings

Serious problems are uncommon, but a few really matter.

Boxed warning. Like all antidepressants, selegiline transdermal carries an FDA boxed warning that it can increase suicidal thoughts and behaviors in children, teenagers, and young adults under 25, especially in the first weeks of treatment or after a dose change.

• Hypertensive crisis. At 9 mg and 12 mg patches, tyramine-rich foods can drive blood pressure to dangerous levels. At 6 mg, tyramine risk is low, but sympathomimetic drugs (some cold medicines, ephedra, some ADHD stimulants, cocaine, amphetamine) can still cause hypertensive events.
• Serotonin syndrome. Combining selegiline transdermal with SSRIs, SNRIs, tramadol, meperidine, dextromethorphan, triptans, linezolid, methylene blue, or St. John's wort can cause severe agitation, fever, muscle rigidity, and altered mental status. Medical emergency. These rules hold at every patch strength.
• Orthostatic hypotension.
• Skin reactions at the patch site, usually mild but occasionally severe.

Sexual side effects

Sexual side effects are less common with selegiline transdermal than with SSRIs or oral MAOIs, though they can occur. This lower rate is one reason selegiline transdermal is sometimes chosen.

Weight, appetite, and sleep

Selegiline transdermal is more weight-neutral than the oral MAOIs. Insomnia and vivid dreams are more common than sedation.

Starting and dosing basics

This section is general background, not a dosing instruction for any individual. The right dose is a decision for a prescriber.

The patch is applied once daily to clean, dry, intact skin on the upper torso, upper thigh, or outer upper arm. Rotate the site each day to reduce skin irritation. Don't cut the patch. Fold used patches sticky sides together before disposal because meaningful drug remains after removal.

Missed doses and interactions

If a patch is missed, apply a new one when you remember. Don't apply two patches at once to catch up.

Interactions are extensive. Common categories:

• Do not combine with SSRIs, SNRIs, other MAOIs, tramadol, meperidine, dextromethorphan, triptans, linezolid, methylene blue, St. John's wort, MDMA, or amphetamines at any patch strength.
• Sympathomimetic decongestants (pseudoephedrine, phenylephrine, over-the-counter cold medicines) need caution at every patch strength.
• Wait 14 days after stopping selegiline transdermal before starting a serotonergic drug (5 weeks after fluoxetine before starting selegiline transdermal).

Give every prescriber and pharmacist a full list of your medications and supplements, including over-the-counter ones. Carry a card that says you take an MAOI.

Stopping and tapering

Selegiline transdermal isn't a controlled substance and isn't habit-forming in the usual sense.

Because the enzyme block is irreversible, effects and interaction risk persist for about two weeks after the last patch. A prescriber typically plans discontinuation carefully, especially if switching to another antidepressant.

Pregnancy and breastfeeding

This is an area where individual circumstances matter and the decision belongs with a clinician. Data in pregnancy are limited. Anyone who is pregnant, planning a pregnancy, or breastfeeding should talk it through with their prescriber so the specific risks and benefits can be weighed for their situation.

Cost and generic availability

Selegiline transdermal is available as a brand-name patch (Emsam). Generic transdermal versions have been limited. Cost varies widely by insurance plan; coverage often requires prior authorization.

Common questions

Do I really not need to follow the tyramine diet at 6 mg? At the 6 mg per 24 hour patch, gut MAO-A is spared enough that dietary tyramine doesn't pose the usual risk. That's the whole clinical appeal of the low-dose patch. Drug interaction rules still apply.

What about at 9 mg or 12 mg? Those doses inhibit gut MAO-A enough that the standard tyramine diet applies.

Is a hypertensive crisis still possible at 6 mg? From food, the risk is low. From sympathomimetic drugs like decongestants, ADHD stimulants, or cocaine, the risk isn't gone. So dietary rules relax at 6 mg but drug rules don't.

Are drug interactions different from oral MAOIs? No. The serotonin syndrome list is the same at every patch strength.

Is it addictive? No. It's not a controlled substance and doesn't cause cravings. Stopping should still be planned with a prescriber.

Questions to ask your prescriber

• Is 6 mg the right dose to start at, and what would push us to go higher?
• Can we go through the drug interaction list together?
• If I need a cold medicine or a dental procedure, what should I do?
• What warning signs should send me to the emergency room?
• If we decide to stop it later, how would we do that safely, and how long do the interaction rules hold after stopping?

Sources

This guide draws on current prescribing information and public health references and current as of June 8, 2026. It is reviewed for clinical accuracy and updated as guidance changes.

• U.S. Food and Drug Administration. Selegiline transdermal system (Emsam) prescribing information.
• MedlinePlus, U.S. National Library of Medicine. Selegiline transdermal.
• National Institute of Mental Health. Mental health medications.
• American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder.
• National Institute for Health and Care Excellence (NICE). NG222, Depression in adults.