Disclosures: Nicholas Annichiarico, DO: No financial relationships or conflicts of interest

Case Description: A 53 year-old male with a traumatic below-knee amputation and a 51 year-old female with a dysvascular below-knee amputation both suffering from refractory residual limb hyperhidrosis.

Setting: Outpatient Clinic Setting

Patient: Both patients presented with severe hyperhidrosis of the residual limb that were refractory to over-the-counter antiperspirants, absorbent capacity of socket, socket changes, and suspension system changes. For their hyperhidrosis, they were both subsequently started on topical glycopyrrolate tosylate. Assessment/

Results: Topical glycopyrrolate tosylate resulted in a clinically significant reduction in residual limb sweating.

Discussion: Sweating occurs via sympathetic innervation with acetylcholine release onto muscarinic receptors on eccrine sweat glands. Hyperhidrosis can occur by several mechanisms including poor temperature regulation as well as maladaptive re-innervation of damaged nerves and de-innervated skin, such as what happens in amputation. Residual limb moisture control is essential in maintaining healthy intact skin and preventing complications from prosthetic use. The use of topical glycopyrronium tosylate, a muscarinic anticholinergic, has only been approved by the Food and Drug Administration for primary axillary hyperhidrosis. Here, we demonstrate successful application of topical glycopyrronium tosylate for the prevention of residual limb hyperhidrosis with an application frequency of every 2-3 days. Alternative pharmacologic treatment includes subcutaneous botulinum toxin injections, and while the frequency of administration is less, the drug must be injected over the entire area of concern with the potential for distant muscle weakness including muscles of phonation and swallowing.

Conclusion: Residual limb hyperhidrosis is an uncommon but debilitating consequence present in amputee patients. These cases demonstrate a novel off-label use for topical glycopyrronium tosylate in the setting of residual limb hyperhidrosis that offers a safer and less invasive alternative to botulinum toxin.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/off-label-use-of-topical-glycopyrrolate-in-residual-limb-hyperhidrosis/