José Francisco Millán-Cayetano

Oral oxybutynin for the treatment of hyperhidrosis: outcomes after one-year follow-up.

Although many treatments are available to address hyperhidrosis, the results are not always satisfactory. The aim of the study was to assess the effectiveness, optimal dosage regimen and long‐term safety of oral oxybutynin in the treatment of hyperhidrosis.

Oral glycopyrrolate after the failure of oral oxybutynin in the treatment of primary hiperhidrosis.

DEAR EDITOR, Oral anticholinergic (ACO) drugs, including oral glycopyrrolate (GLY) and oxybutynin, offer proven efficacy and safety in the management of hyperhidrosis, although they are not currently approved for this indication. Oral oxybutynin has been used most frequently for this purpose and has also appeared in the greatest number of studies, showing a good rate of response with frequent but well-tolerated adverse effects. Fewer studies have demonstrated the effectiveness of oral GLY for the treatment of hyperhidrosis. However, to date no published studies have focused on the use of a particular ACO drug in patients for whom previous treatment with a different ACO drug had failed. In this study, our aim was to evaluate the effectiveness and safety of GLY in treating patients with hyperhidrosis for whom oxybutynin had failed. In this prospective observational study, GLY was prescribed to patients diagnosed with primary hyperhidrosis between January 2012 and October 2014, for whom previous treatment with oral oxybutynin had failed. GLY was provided at gradually increasing dosages, individualized according to response and tolerance, starting at 2 mg per day and increasing to up to 9 mg per day. The patients’ sociodemographic and clinical characteristics were recorded, together with their response and tolerance to treatment at 3 and 12 months. The specific validated Hyperhidrosis Disease Severity Scale (HDSS) was used to measure the intensity of sweating and to evaluate the response to treatment. The response was considered ‘excellent’ when the HDSS score decreased by 2 points (which correlated with an 80% improvement in hyperhidrosis), or when a final score of 1 was achieved. A ‘partial response’ was defined as an improvement of 1 point. The treatment was considered a failure when the HDSS score remained similar or worsened, or if patients were intolerant to treatment. The study group consisted of 23 patients, whose characteristics are summarized in Table 1. All presented multifocal (more than one location) or generalized hyperhidrosis. After starting treatment with GLY, the duration of follow-up ranged from 3 to 39 months (median 15 months) and the usual daily dosage was 2–9 mg per day, with an average daily dosage of 3 4 mg per day at 3 months and 4 2 mg per day at 12 months. At 3 months after initiating treatment, the response was excellent for 15 patients (65%) and partial for four patients (17%). On the other hand, four patients had stopped treatment; two because of adverse effects and two because of a lack of effectiveness. Between the 3and 12-month follow-up examinations, another seven patients left the study: two because of adverse effects, two owing to ineffectiveness, two patients independently decided to discontinue treatment and one patient left the study because of both adverse effects and ineffectiveness. At 12 months, 10 of the 13 patients who were continuing treatment presented an excellent response, two presented a partial response and one had no response (Fig. 1).

Refractory acne keloidalis nuchae treated with radiotherapy

Acne keloidalis nuchae (AKN) is difficult to treat, and the clinical response is usually poor. Few reports have been published about scarring alopecia treated with radiotherapy (RT). We report a case of AKN that had been refractory to various other treatments but which responded to RT with excellent clinical and cosmetic results.

BRAF V600E Mutation in Involuting Nevus in a Patient Treated With Vemurafenib

BRAF V600E Mutation in Involuting Nevus in a Patient Treated With Vemurafenib Vemurafenib is considered a first-line treatment for unresectable or metastatic malignant melanoma (MM) with V600E mutation of the BRAF gene (OMIM 155600). Among its many adverse effects are regressive changes, the development of increasing atypia in preexisting nevi, and the appearance of second melanomas.1-4 Increasing atypia can be explained by a paradoxical pathway activation of mitogen-activated protein (MAP) kinases in cells with no mutation.1 This process would also account for the appearance of second, wild-type, melanomas. It has been hypothesized that changes in the nevi with regression are caused by the presence of mutated nevus cells, which respond to treatment in the same way as those of the primary MM.2 However, to our knowledge, this hypothesis has been corroborated by only 1 study,5 which reported the case of a patient treated with dabrafenib for a metastatic MM who developed regressive changes in some nevi. The nevus cells of the involuting lesions presented the same mutation.5

Adjusting oral oxybutynin medication for hyperhidrosis to reflect seasonal temperature variations

Most studies of oral oxybutynin (OOx) for the treatment of hyperhidrosis (HH) have assumed a stable treatment protocol, without taking into account adverse effects (AE) or seasonal variations in temperature. The objective is to evaluate adjusting the dose of OOx according to the time of year. Prospective study of patients who began OOx for HH between 2007 and 2017, and maintained treatment for at least 1 year, with a progressively increasing dose was performed. All patients were recommended to vary the dose of medication according to the time of year. Baseline epidemiological data, the response to treatment and AE were analyzed. About 122 patients were included (average age of 33.8 years). Up to 60.7% varied the dose. Significantly better results were obtained in the group that varied the dose. Twenty patients suspended the treatment in winter. Among them the adjusted OR was 3.04 (95% CI 1.24–7.45) for an excellent response. The frequency of AE was 74.6% with no differences among groups. Most patients are able to control their HH without requiring the same dose of OOx throughout the year. Given that the possible AE of OOx are dose‐dependent, it seems reasonable to vary it according to the time of year.

Initial study of transdermal oxybutynin for treating hyperhidrosis

Oral oxybutynin for treating hyperhidrosis is effective and safe. Its side‐effects are mild but frequent so we consider whether transdermal oxybutynin (considered to have a better side‐effect profile) could be an alternative for treating hyperhidrosis. During 2015, a prospective study was conducted. Epidemiological variables, effectiveness (using the Hyperhidrosis Disease Severity Scale) and tolerance to transdermal oxybutynin were compiled concerning two different groups (patients previously treated or untreated with oral oxybutynin), at baseline, and at 3 and 12 months. Seven previously treated and six previously untreated patients were included. Five patients in the first group discontinued the treatment within 3 months. Of the two remaining patients, one reported ineffectiveness and the other obtained an excellent response but discontinued due to local irritation. Among the untreated patients, two showed no response and four experienced improvement (three with “partial response” and one with “excellent response”). All patients discontinued treatment within 12 months. No major adverse effects were observed. The absence of active metabolites after transdermal oxybutynin could result in less effectiveness than oral oxybutynin, although it is usually well tolerated. In conclusion, transdermal oxybutynin could have low effectiveness for the treatment of hyperhidrosis in patients following intolerance to oral oxybutynin but could provide good results in patients who have never tried systemic drugs.

Treatment of red tattoo reaction using CO2 laser

Tattooing is an ancient form of body art which appeared many thousand years ago. However, it is nowadays when it is evolving into a very common fashion practice, with a usage ranging from 5 to 40% in adults. The tattoos are based in the placement of pigmented foreign body material in the dermal layer of the skin using needles. This technique can produce a wide variety of adverse local effects (infections, appearance of neoplasms, reactivation of underlying dermatosis and allergic and toxic reactions) or even systemic effects. Many dyes may be used for this procedure, but it is red dye, the one that causes most of the clinical adverse effects. These red inks are classified as inorganic (mercury, cinnabar, cadmium, selenium, ferric hydrate) or organic (sandalwood, brazilwood) [1]. Many red tattoo reactions have been described, but it is the lichenoid pattern, the most frequent, followed by pseudolimphomatous, granulomatous, spongiotic or necrobiotic among others. No matter which kind of histopathological pattern is presented, they can produce intense itching and a great distress in the quality of life of the affected patients. Once the reaction has appeared, the common treatments include topical, intralesional or oral corticosteroids, antibiotic with anti-inflammatory effects, allopurinol and immunosuppresive agents. Nevertheless, there is no evidence about which is the most appropriate treatment. It would make sense that destructive methods, as surgery, would be the most effective, but depending on the location and the size of the tattoo, surgical excision is not always the best choice. Few reports just based on isolated cases have been published about laser treatment for the management of red ink reactions.

Survival study of treatment adherence by patients given oral oxibutynin for hyperhidrosis

In recent years, increasing use has been made of oral anticholinergics such as oxybutynin for the management of hyperhidrosis. The primary aim of this study is to determine the variables associated with adherence to this treatment, and secondarily to obtain data on its effectiveness, safety and adverse effects.