Therapeutic treatment of multiple eccrine hidrocystomas with topical glycopyrronium tosylate 2.4% solution

Introduction

Eccrine hidrocystomas are uncommon cystic lesions that develop benign tumors in sweat glands, mostly in the malar, periorbital, chest, axilla, and neck areas. Ranging from 1 to 6 mm in diameter, they typically present in adults, with a predominance for women.¹ They can enlarge in hot conditions and their treatment may be especially challenging.² We report a case of multiple eccrine hidrocystomas on the periorbital area in a middle-aged woman successfully treated with topical glycopyrronium tosylate 2.4% solution in cloth towelette.

Case report

A woman in her late 40s with a history of hypothyroidism presented with an asymptomatic papular eruption over the left periorbital area that had been present for approximately 1 year. The patient reported that the lesions had recently expanded and were not treated previously. Physical examination revealed multiple, dome-shaped, flesh-colored, 1- to 2-mm papules (Fig 1, A). Histologic examination showed a cystic lesion within the dermis, lined by 1 to 2 layers of small, basophilic, cuboidal epithelial cells, consistent with the diagnosis of eccrine hidrocystoma (Fig 2). Treatment with topical glycopyrronium tosylate 2.4% solution in cloth towelette was tested, with instructions for the patient to apply the solution to the site every day sparingly until the papules faded. She reported significant clinical improvement within 1 week (Fig 1, B) and she tolerated the treatment well, without any adverse effects. The patient has maintained resolution of the hidrocystomas with a regimen of applying the topical solution to the affected site 2 to 3 times per week.

Fig 1.

Multiple eccrine hidrocystomas on the left forehead and left cheek. A, Before therapy. B, Response after 1 week of daily application of topical glycopyrronium tosylate 2.4% solution.

Fig 2.

Lesional biopsy specimen showing a cystic lesion within the dermis, lined by 1 to 2 layers of bland ductal epithelium. (Hematoxylin-eosin stain; original magnification: ×200.)

Discussion

A variety of nonpharmacologic treatments have been used for eccrine hidrocystomas with varying rates of success, including needle puncture, electrodessication, carbon dioxide laser vaporization, and laser treatment.¹ Because eccrine activation is driven by cholinergic pathways,³ anticholinergic medications are reasonable treatment options for patients with eccrine hidrocystomas that are bothersome. Oral anticholinergic medications, including oxybutynin and glycopyrrolate, have been reported to treat hidrocystomas successfully.^2,4 However, oral medications pose significant risk of systemic adverse effects, such as dry mouth, blurred vision, and vomiting.

Topical, rather than oral, anticholinergic medications may represent the safest long-term therapy for eccrine hidrocystomas because of the lower likelihood of systemic absorption. Sanz-Sánchez and colleagues³ performed a head-to-head study to compare the efficacy of 3 topical anticholinergic medications (1% atropine sulphate, 40% scopolamine butylbromide, and 1% ipratropium bromide) in patients with multiple hidrocystomas and found all to be well tolerated, although topical ipratropium was the only medication to result in complete remission. Topical anticholinergic glycopyrrolate 0.5% in aqueous solution has been reported in the literature only once previously, in 2010, to successfully treat eccrine hidrocystomas in a patient with concurrent craniofacial hyperhidrosis.⁵

The topical glycopyrronium tosylate 2.4% solution in cloth towelette used by our patient was approved in June 2018 by the Food and Drug Administration as the first and only topical anticholinergic to treat primary axillary hyperhidrosis in adult and pediatric patients aged 9 years and older.⁶ To the best of our knowledge, this is the first case report to demonstrate resolution of multiple eccrine hidrocystomas with this novel application method of glycopyrronium tosylate. Because this drug is a topical anticholinergic, there is a risk of blurred vision, mydriasis, and dry mouth with periocular or perioral absorption.⁷ For this reason, use of disposable gloves has been proposed as a safety measure to reduce manual transfer.⁸ The patient described in this report has not noted any systemic anticholinergic adverse effects and continues to maintain clearance with targeted facial application 2 to 3 times per week.

Due to its clinical promise, accessibility, favorable safety profile, unique mechanism of action, and ease of application for patients, we believe that 2.4% topical glycopyrronium tosylate in cloth towelette should be considered by physicians treating this condition. It is our hope that the efficacy of this medication in our patient will prompt further study of this drug for treating multiple eccrine hidrocystomas in larger sets of patients.