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THERAPEUTIC ROUND

Year : 2010 | Volume : 55 | Issue : 1 | Page : 47--49

Topical 0.03% atropine vs. 15% aluminum chloride in treating
multiple eccrine hidrocystomas: A randomized single blind
controlled study

Ehsani Amirhoushang, Mirshams Shashahani Mostafa, Akhyani Maryam, Noormohamadpour
Pardis, Noormohamadpour Pedram
Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
Correspondence Address:
Noormohamadpour Pedram
Vahdate eslami Sq, Vahdate-Eslami Ave. Razi Hospital, 11996, Tehran
Iran

Abstract

Background: Multiple eccrine hidrocystomas pose a significant treatment challenge due
to their facial location and tendency to scar after traditional surgical and other
destructive modalities.Aims: To compare two frequently used non-destructive
therapeutic modalities. Materials and Methods: Thirty patients with multiple eccrine
hidrocystomas were enrolled in the study. They used topical 0.03% Atropine cream and
15% AlCl
3
solution on left and right sides of their face randomly for 4 weeks. All the
patients were visited before commencing the therapy as well as two and four weeks later
by a dermatologist, blinded to the drugs and the number of lesions. Results: Twenty
nine patients (25 females, four males) completed the study. The mean reduction in the
number of lesions was significantly higher with Atropine cream in comparison with
AlCl
3
solution, 10.2±7.4 vs. 6.2±5.3 ( P < 0.05). There were no recurrences after three
months follow-up in both groups.Conclusion: It seems that both Atropine and AlCl
3
are
useful therapies in eccrine hidrocytomas but the former might be more effective. We
think that other randomized clinical trials with larger sample sizes are needed.

How to cite this article:
Amirhoushang E, Mostafa MS, Maryam A, Pardis N, Pedram N. Topical 0.03% atropine vs. 15%
aluminum chloride in treating multiple eccrine hidrocystomas: A randomized single blind
controlled study.Indian J Dermatol 2010;55:47-49

How to cite this URL:
Amirhoushang E, Mostafa MS, Maryam A, Pardis N, Pedram N. Topical 0.03% atropine vs. 15%
aluminum chloride in treating multiple eccrine hidrocystomas: A randomized single blind
controlled study. Indian J Dermatol [serial online] 2010 [cited 2014 May 22 ];55:47-49
Available from: http://www.e-ijd.org/text.asp?2010/55/1/47/60352

Full Text
Introduction


Eccrine hidrocystomas are benign cystic lesions which originate from eccrine glands duct
[1] predominantly located on the face - eyelid and cheek regions. [2],[3]

These lesions are more frequent in females than males. [4] They present as a 1-3 mm
translucent yellowish to slightly blue cysts. Eccrine hidrocystoma is currently classified in
two subtypes according to the numbers of lesions. [5] Multiple cysts frequently present
in periorbital, forehead and malar regions and progress under high temperature and
excessive sweating. [3] Treatment of multiple eccrine hidrocystoma lesions is
questionable despite the good response of solitary lesion to surgical excision; because of
their location and subsequent cosmetic complication. [1]

Therapeutic options include medical and surgical modalities. Surgical excisions,
electrocuterry, dermabrasion, topical and oral anticholinergic agents, [1],[6],[7]
botulinum toxin [8] And Pulsed-Dye Laser [9] have been reported as treatment options
in these cases.

Despite all these attempts, an agreed-upon treatment for this condition has not yet been
formulated. Regarding the eccrine origin of the lesions, the pathogenesis of eccrine
hidrocystoma is particularly similar to hyperhydrosis. Hence the first line treatment for
hyperhidrosis is 20% (AlCl 3 .6H 2 O) in absolute alcohol. [10] This solution seems to be
a reasonable option for the treatment of eccrine hidrocystoma as well.
Materials and Methods


The study aims to assess the efficacy and safety of 15% (AlCl 3 .6H 2 O) in absolute
alcohol solution in treatment of multiple eccrine hidrocistoma compared with topical
Atropine 0.03% in cream based on eucerin. In consultation with a pharmacologist
assistant, we found that we could not prepare stable solution based Atropine, so we had
to use cream based Atropine preparation. Also, to minimize the risk of local irritation, we
used 15% (AlCl 3 .6H 2 O) in absolute alcohol solution instead of 20% solution.

The study was designed as a randomized, single blind, controlled trial. All the volunteer
patients who referred to our clinic with diagnosis of multiple eccrine hidrocystoma during
the summer of 2007, after confirming the diagnosis by three board certified academic
dermatologists, were eligible for the study. The study was conducted in accordance with
Declaration of Helsinki and approved by the local ethics committees.

Patients were excluded if they had received any treatment for these lesions in the
previous year (apart from sunscreens), were pregnant or had any history of sensitivity to
drugs used in the study. Diagnosis of eccrine hidrocystoma was confirmed through
clinical examination by three Board certified academic dermatologists based on clinical
grounds such as multiplicity of lesions, recurrent nature of them and weeping fluid when
pricked by needle, and number of lesions on each side of face was recorded in special
questionnaires.

During the study period, no other therapeutics was used. After informed consent, 30
patients were enrolled in this study. All patients had multiple eccrine hidrocystoma
lesions on both sides of their face. For each patient, a questionnaire was completed and
appropriate method of solution and cream application was actually demonstrated. For
each patient, 15% AlCl 3 in absolute alcohol and Atropine containing cream randomly
prescribed for different sides of face lesions by a participating dermatologist as manager
of research. Hence, some patients received solution on right side lesions and cream on
left side lesions and vice versa for others. Patients were advised against use of Atropine
containing cream very near the eyelids (a distance of at least 0.5 cm should be
considered). This information stored secure for each patient and participating examiner
dermatologist was blinded to this information. Patients visited at second and fourth
weeks after beginning the study and were examined by the dermatologist; any changes
in number of lesions were documented in special questionnaires designed for this
purpose. One patient was excluded from study after he discontinued his treatment
regimen.

Patients applied solution and cream to absolutely dry skin at bed time, 30 to 60 minutes
after cleansing the face with water; they washed the face with water the following
morning. If there were any signs of irritation or other sensitivity to any drug used, the
therapy was discontinued.

Statistical analysis

Data analysis was performed using SPSS for windows (v 13.0) statistical package. t-test
used for comparisons. The differences were statistically significant for P Side effects

Dryness of skin (30%) and local skin irritation (7%) were significant adverse effects of
cream containing 0.03% Atropine, and we had no ophthalmic side effect. Adverse effects
in the 15% (AlCl 3 .6H 2 O) group were burning sensation and local irritation (22%),
erythema (10%), and dryness and skin (25%). One patient discontinued the therapy
following severe irritation caused by the solution. All of her skin irritation cleared with a
week's use of topical triamcinolone.
Results


Twenty nine patients, 25 (86.2%) female and four (13.8%) male completed the study.
The age range of patients was between 29 to 61 years, with the mean age of 40.5±8.74
and 43.6±7.59 years for men and women, respectively.

Before commencing the therapy, mean number of lesions on each side of face was
20.5±13.4 for left side and 20.7±12.9 for right side of the face ( P > 0.1, not
significant). After four weeks of therapy, mean reduction of lesions was 10.2±7.4 and
6.2±5.3 for Atropine cream and (AlCl 3 .6H 2 O) in absolute alcohol solution,
respectively ( P 3 .6H 2 O) in absolute alcohol solution, and reduction rate is about 50%.
There were no recurrences after three months follow-up in both groups.
Discussion


AlCl 3 .6H 2 O produces Aluminum ion and hydrochloric acid in the presence of water.
The produced acid can cause skin irritation and damage. [11] Therefore, it is imperative
to apply this solution to absolutely dry skin, never in less than 30 minutes to two hours
after washing. Also the solution should not be used on irritated, wet, ulcerated, or
recently shaved skin. It is recommended to apply the solution at bed time, and wash the
skin the following morning. [10],[12],[13]

The antiperspirant mechanism of AlCl 3 .6H 2 O is by physical blockage of sweat gland
ducts and vacuolization and atrophy of secretary cells. It penetrates to terminal end of
eccrine ducts in epidermis by reflux entrance and causes shrinkage of the ducts.
[10],[12]

Atropine 1% ointment or solution in case reports has been used in eccrine hidrocystoma
management successfully but several anti cholinergic side effects such as blurred vision
or mouth dryness were seen after this therapeutic option. [7] Because of these adverse
effects, we used a lower concentration of atropine (0.03%) and as said earlier, we had
no ocular side effects or dryness of oral mucosa. At least in one study topical atropine
ointment was unsuccessful in treating multiple eccrine hidrocystomas. [14]

Surgical excision of individual lesions is effective but limited by the risk of scarring and
ectropion formation. [15],[16] Lesional drainage and cautery are other therapeutic
modalities in eccrine hidrocystomas but frequently; recurrence of lesions after three to
six weeks were noted [17] although in the present study we had no recurrences after
three months of follow-up in both the enrolled groups.

A 585-nm flashlamp-pumped pulse dye laser (PDL) leads to satisfactory improvement in
eccrine hidrocystomas, without recurrence 18 months after. [18] There are reports
questioning the effect of PDL on multiple eccrine hidrocystoma. [19]

In comparison to these therapeutic modalities, 0.03% Atropine cream and, 15% AlCl 3
.6H 2 O are not consuming and low cost without any significant adverse effects. In
conclusion, it seems that both these therapies are effective in eccrine hidrocystomas
treatement and 0.03% Atropine cream is significantly better than 15% AlCl 3 .6H 2 O,
although we think other randomized clinical trials with larger sample sizes are needed.
Acknowledgment


This work was supported by a Grant from Undersecretary of Research, Tehran University
of Medical Sciences.
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