Glycopyrronium bromide cream for prevention of chronic-relapsing candidiasis of submammary folds: preliminary results of a sponsor-free study

Dear Editor,

Candidiasis of skin folds is a common infection, usually caused by Candida albicans. In particular, candidiasis of submammary folds occurs in adult females. It is characterized clinically by more or less widespread erythematous lesions, often with a follicular arrangement. Pruritus is often severe. Topical and oral azoles are the treatment of choice. Obesity, diabetes, AIDS, neoplasms and drugs (estroprogestationals, antibiotics, corticosteroids, immunosuppressive drugs, antitumorals) and radiotherapy can predispose individuals to develop candidiasis. Furthermore, hyperhidrosis is an important local predisposing factor. Topical anticholinergics, and in particular topical glycopyrronium bromide, at concentrations ranging from 0.5 to 2%, have been shown to be effective for the treatment of hyperhidrosis of axillae in some controlled studies (1–4). A group of seven Caucasian females, who ranged in age from 43 to 73 years (mean age: 56.3 years), with chronic-relapsing candidiasis of submammary folds (1–2 recurrences/month), were treated with 1% glycopyrronium bromide cream in order to reduce hyperhidrosis and maceration and, consequently, to reduce the risks to develop candidiasis. The treatment was started when clinical examination of submammary folds was negative for candidiasis. The cream was applied once daily for one month, subsequently every other day for one month. We suggested to apply the same amount of cream (2 pumps) for each submammary fold. Six patients were overweight or obese, five patients had diabetes and one patient was affected by bronchiectasis. Five patients were in therapy with metformin, three with rosuvastatin, two with candesartan or orlistat, one each with simvastatin, nifedipine, atenolol, bisoprolol, bupropion/naltrexone and liraglutide. Furthermore, one patient was in therapy with chronic-pulsed azithromycin for bronchiectasis.

Six out of seven patients did not develop relapses of candidiasis during the two months of study. One patient developed submammary candidiasis six weeks after the beginning of the treatment. One patient reported mild burning sensation at the sites of application of the cream and one patient reported transitory dry mouth of little importance: in both cases, it was not necessary to stop the treatment. During a three month follow up, five patients developed at least one recurrence. Although the small group of patients, the results of this study may be summarized as follows: (a) 1% glycopyrronium bromide cream can be used in order to prevent chronic-relapsing candidiasis of submammary folds; (b) the cream was well tolerated. Abels et al. treated 171 patients with primary axillary hyperhidrosis in a 4-week, multicenter, randomized, double-blind, placebo-controlled, phase III pivotal study. Local tolerability was good: 9% of patients developed only mild or moderate reactions at the sites of application of the cream. Dry mouth, an expected anticholinergic effect of glycopyrronium bromide, was reported in 16% of patients (2). Patients (n. 518) with severe primary axillary hyperhidrosis were treated with 1% glycopyrronium bromide cream once daily for 4 weeks, followed by a flexible dosage scheme (from once/day to twice/week), for a total of 72 weeks. Mild to moderate local erythema and dry mouth were the most common side effects (4); (c) as previously mentioned, during a three month follow up, five out of seven patients developed at least one recurrence: this justifies a long term use of the cream (2 applications/week, as suggested by Szeimies et al.?) (4). Also the duration of the treatment must be evaluated in a future clinical study; (d) it is possible that hyperhidrosis, and not other factors, is the most important cause of candidiasis of submammary folds.

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The authors do not have any conflict of interest. This research did not receive any specific grant.

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