Dilated pupils caused by topical glycopyrrolate for hyperhidrosis

Abstract

There are numerous cutaneous manifestations of hypothyroidism, the most notable of which is periorbital and facial oedema. Only upper limb oedema was present in our patient and this obscured the clinical diagnosis. Some scaling and xerosis were noted on the upper arms during the later stages but other features such as pale, cold, wrinkled skin with punctate telangiectasias, palmoplantar keratoderma and absence of sweating were not present.The noncutaneous manifestations of hypothyroidism are weight gain, cold intolerance, constipation and poor concentration. Musculoskeletal symptoms are common but reports of proximal muscle weakness and elevated creatine kinase are rare. Madariaga et al. 1 found only 32 published cases over a 25-year period between 1975 and 2000.The presence of mucin in the biopsy specimen and musculoskeletal symptoms is compatible with a diagnosis of thyroid disease, dermatomyositis, and systemic lupus erythematosus. 2 Our case is similar to that previously reported by Ohtsuka et al. 3 who described dermal mucinosis and musculoskeletal symptoms simulating polymyositis as a presenting sign of hypothyroidism. However, their patient had facial oedema, dry skin and a goitre suggesting the diagnosis.The cutaneous mucinoses can be classified into primary and secondary forms depending upon whether mucin deposition is a distinct histological feature or an indistinct feature associated with various pathologies. 4 The primary mucinoses are scleromyxoedema, acral persistent papular mucinosis, scleredema, nodular and papular mucinosis, and mucinosis associated with thyroid disease. Nodular and papular mucinosis has been associated with systemic lupus erythematosus 5 and acral persistent papular mucinosis with dermatomyositis. 6 This is an atypical presentation of hypothyroidism and highlights the importance of determining thyroid function in patients presenting with musculoskeletal symptoms and ⁄or cutaneous mucin deposition. Obvious signs of hypothyroidism may be absent. Other rare manifestations of hypothyroidism can similarly cause difficulty in diagnosis leading to a delay in treatment, 'myxoedema madness' being the well-known example. Amelioration of symptoms and normalization of creatine kinase levels in response to prednisolone and methotrexate reflects their nonspecific actions, and provides an illustration of how this can mislead the clinician.

Topical Oxybutynin 10% Gel for the Treatment of Primary Focal Hyperhidrosis: A Randomized Double-blind Placebo-controlled Split Area Study

“…Topical anticholinergic agents, such as glycopyrrolate, have had inconsistent efficacy in improving sweating (5-10) and were more effective for the sweating of the craniofacial area than other areas (7). Their effect may be partly systemic due to transdermal absorption and distant effect (11)(12)(13). Al though many systemic anticholinergic adverse effects (dry mouth, blurry vision, constipation, difficulty in urinating, cognitive and memory impairments) can be attributed to oxybutynin, which is another cholinergicmuscarinic receptor antagonist, several peer-reviewed articles that included long-term use reported high levels of safety for its treatment of various pathologies, especially when used orally in low and incremental doses or topically (14,(44)(45)(46)(47)(48)(49).…”

“…Hypohidrosis is associated with systemic anticholinergic drugs (4), which led to their use as topical agents for hyperhidrosis. For example, topical application of the anticholinergic drug glycopyrrolate (5)(6)(7)(8)(9)(10) resulted in focal improvement in sweating, although that effect may have been due in part to systemic absorption of the medication (11)(12)(13).…”

A medical alternative to the treatment of compensatory sweating

“…Its main side effects when used topically are dry mouth and throat and mild skin dryness or irritation. However, recently there have been single reports of urinary retention, mydriasis, and accommodative failure (5,7,8,15). It is possible that the increased absorption can be attributed to the use on the relatively thin skin of the axilla in comparison to the thicker soles and palms.…”

“…Like other anticholinergics, it acts by preventing the acetylcholine‐induced stimulation of the sweat gland receptors. Its advantage over other agents is its inability to cross the blood–brain barrier, consequently producing fewer side effects (5–16).…”

A 15-year-old girl with variable anisocoria

“…Once this has been ruled out, Adie's tonic pupil must be considered. Other causes of mydriasis and accommodative failure include temporal lobe epilepsy, 1 migraine, 2,3 use of topical and systemic medications, [4][5][6] or exposure to plant toxins. 7,8 …”