Oral Glycopyrrolate for Primary Focal Hyperhidrosis in a Pediatric Population: A Cross-Sectional Study

To the Editor: Primary focal hyperhidrosis (PFH) is characterized by uncontrollable, excessive sweating in an otherwise healthy individual—typically involving the axillae, palms, and soles.1Remington C. Ruth J. Hebert A.A. Primary hyperhidrosis in children: a review of therapeutics.Pediatr Dermatol. 2021; 38: 561-567Crossref PubMed Scopus (0) Google Scholar Hyperhidrosis can negatively impact the psychosocial well-being of adolescent patients and is associated with depression in adults.2Paller A.S. Shah P.R. Silverio A.M. Wagner A. Chamlin S.L. Mancini A.J. Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis.J Am Acad Dermatol. 2012; 67: 918-923Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,3Bahar R. Zhou P. Liu Y. et al.The prevalence of anxiety and depression in patients with or without hyperhidrosis (HH).J Am Acad Dermatol. 2016; 75: 1126-1133Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar When topical therapy is inadequate to manage hyperhidrosis, treatment with oral glycopyrrolate should be considered.1Remington C. Ruth J. Hebert A.A. Primary hyperhidrosis in children: a review of therapeutics.Pediatr Dermatol. 2021; 38: 561-567Crossref PubMed Scopus (0) Google Scholar,2Paller A.S. Shah P.R. Silverio A.M. Wagner A. Chamlin S.L. Mancini A.J. Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis.J Am Acad Dermatol. 2012; 67: 918-923Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,4Kumar M.G. Foreman R.S. Berk D.R. Bayliss S.J. Oral glycopyrrolate for refractory pediatric and adolescent hyperhidrosis.Pediatr Dermatol. 2014; 31: e28-e30Crossref PubMed Scopus (17) Google Scholar However, there are few studies and no widely accepted guidelines on the use of this systemic medication to treat pediatric patients with PFH. Uniquely challenging for adolescents is the need to balance adverse side-effects with treatment approaches that increase participation in school and extracurricular activities during developmentally critical periods. We conducted a retrospective chart review of patients <19 years old at initial diagnosis of PFH seen at Rady Children's Specialists of San Diego Dermatology Clinics between February 10, 2011 and February 10, 2021. Inclusion in this study and the clinical data were based on EPIC SlicerDicer searches of the >2 million patients in our electronic health records using the following International Classification of Diseases codes: 705.2, L74.510, L74.511, L75.512, L75.513, and L74.519. Analyses were performed using the t test, chi-square test, and logistic regression. This study was approved by the University of California San Diego institutional review board. Patients seeking care for hyperhidrosis were predominantly female (61.9%) and the median age at initial presentation to dermatology was 14.6 years (Table I). The patient's racial/ethnic identification was reflective of the San Diego metropolitan area. Fifteen percent (n = 191) with a median age of 15.7 years were prescribed oral glycopyrrolate at a mean daily dose of 3.3 mg (0.056 mg/kg/d) (Table II). Of these patients, the following sites of involvement were reported: 24 (12.6%) hands only, 17 (8.9%) axillae only, 0 (0.0) feet only, 48 (25.1%) palmoplantar, 24 (12.6%) hands and axillae, and 81 (42.4%) >2 anatomic areas. On multivariate analysis, older age (odds ratio 1.16, 95% CI 1.09-1.23, P < .001) and female gender (odds ratio 1.79, 95% CI 1.27-2.53, P < .001) were positively associated with electronic prescriptions for oral glycopyrrolate, whereas insurance type and race were not.Table IPatient characteristics overall (N = 1299) and prescriptions for oral glycopyrrolatePatient characteristicsTotal (N = 1299)Oral glycopyrrolate therapy (N = 191)No oral glycopyrrolate therapy (N = 1108)P value∗P value statistically significant if α < .05Median age at initial visit (range), years14.6 (0.43-18.97)15.2 (7.3-18.8)14.4 (0.43-18.97)<.001Female sex, % (n)61.9 (804)72.3 (138)60.1 (666).002Race, % (n).23 Hispanic50.3 (653)52.9 (101)49.8 (552) White40.5 (526)36.6 (70)41.2 (456) Asian/Pacific Islander3.2 (41)2.6 (5)3.2 (36) Black/African American2.5 (33)4.7 (9)2.2 (24) No race specified3.5 (46)3.1 (6)3.6 (40)Insurance type, % (n).3 Unknown/uninsured61.4 (797)67.5 (129)60.3 (668) Private23.6 (306)20.4 (39)24.1 (267) Public7.9 (102)6.3 (12)8.1 (90) Other government insurance7.2 (94)5.8 (11)7.5 (83)∗ P value statistically significant if α < .05 Open table in a new tab Table IIPatients treated with oral glycopyrrolateOral glycopyrrolate therapy (N = 191)Median age in years when prescribed oral glycopyrrolate (range)15.7 (8.2-19.1)Location of involvement, % (n) Hands only13.1 (25) Axillae only8.9 (17) Feet only0.0 (0) Palmoplantar25.7 (49) Hands and axillae12.6 (24) Multifocal (>2 locations)39.8 (76)Specified38.7 (74)Not specified1.0 (2)Mean dose (mg/day)3.3Mean weight-based dose (mg/kg/day)0.056 Open table in a new tab Body image and peer relationships are central to adolescent development, yet their influence on treating hyperhidrosis is not well understood. This study provides evidence that patient-provider decisions regarding treatment are not neutral with respect to sex and age and that a sizable proportion of patients diagnosed with PFH are <15 years old. It is plausible that for children and adolescents, regardless of perceived benefit, families and providers might not feel comfortable using a long-term systemic medication for this disorder. Less clear is an explanation for how gender norms might influence treatment. We speculate that the mean weight-based dose of 0.06 kg per day glycopyrrolate observed likely reflects a balance of provider comfort and dose efficacy. Our findings do not determine a causal relationship or assess the efficacy of oral glycopyrrolate but rather provide insight into designing future studies. Prospective studies are needed that address efficacy and evidence-based dosing strategies, as well as quality of life and shared decision-making in children and adolescents. None disclosed. The Research Informatics team at Rady Children's Hospital San Diego performed the EPIC SlicerDicer-based data extractions.