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Hyperhidrosis, or excessive sweating, is a disorder that may cause social isolation or occupational disability. It may be generalized or localized, and although frequently idiopathic it may be a manifestation of a number of important systemic diseases. Drugs, surgical procedures, and electrical devices may all be employed by the physician as therapeutic weapons to treat hyperhidrosis.
Physiological sweating from cutaneous eccrine glands maintains normothermia and skin hydratation. Hyperhidrosis, a pathological condition caused by excessive secretion of the eccrine sweat glands, is divided into physiologic, symptomatic and idiopathic type. Contemporary methods of hyperhidrosis treatment, in particular botulinum toxin injections are discussed.
Excessive sweating from the palms and soles, known as palmoplantar hyperhidrosis, affects both children and adults. Diagnosis of this potentially embarrassing and socially disabling condition is based on the patient's history and visible signs of sweating. The condition usually is idiopathic. Treatment remains a challenge: options include topical and systemic agents, iontophoresis, and botulinum toxin type A injections, with surgical sympathectomy as a last resort. None of the treatments is without limitations or associated complications. Topical aluminum chloride hexahydrate therapy and iontophoresis are simple, safe, and inexpensive therapies; however, continuous application is required because results are often short-lived, and they may be insufficient. Systemic agents such as anticholinergic drugs are tolerated poorly at the dosages required for efficacy and usually are not an option because of their associated toxicity. While botulinum toxin can be used in treatment-resistant cases, numerous painful injections are required, and effects are limited to a few months. Surgical sympathectomy should be reserved for the most severe cases and should be performed only after all other treatments have failed. Although the safety and reliability of treatments for palmoplantar hyperhidrosis have improved dramatically, side effects and compensatory sweating are still common, potentially severe problems.
A case of a cervical intramedullary tumor is reported whose presentation was with disabling hyperhidrosis. The symptom resolved after surgical debulking of the tumor. Hyperhidrosis as a presenting manifestation of an intramedullary tumor has not been reported earlier.
Primary axillary hyperhidrosis is a medical condition characterized by excessive underarm sweating that is thought to result from localized hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers. It can be associated with significant professional, physical, and emotional impairment as well as considerable difficulties in social situations and in personal relationships. Available therapies have been limited by short-lived effectiveness and in some cases significant adverse effects that can put patients at risk for potentially serious complications. Chemodenervation of sweat glands using botulinum toxin type A (BTX-A), which has long-lasting therapeutic efficacy with minimal adverse effects, has emerged as a unique therapy for treating primary axillary hyperhidrosis. This article reviews the chemodenervation procedure, including patient preparation, BTX-A administration, and patient assessment and follow-up.
Bilateral simultaneous transaxillary sympathectomies (BSTS) were established in order to achieve a one-stage transaxillary sympathectomy in the treatment of palmar hyperhidrosis. The features of the BSTS were the patient's supine operative position, parapectoral incision, and bilateral simultaneous procedures. BSTS were safely performed on 60 patients during a 5-year period. No serious complications or recurrences were encountered. The clinical results suggest that BSTS is the technique of choice for one-stage transaxillary sympathectomy in the treatment of palmar hyperhidrosis.
Hyperhidrosis is excessive sweating in response to psychological stress and emotional stimuli. The sweat is usually limited to the palms, soles, and axillae, and is greatly accentuated by mental stimuli rather than temperature and exercise. The severity is such that for many, sweating has become socially and emotionally devastating and may predispose to other cutaneous diseases. More than 60 research papers on eccrine glands and sweating have been published since 1978. Little progress, however, has been made on the control of hyperhidrosis, and the process remains a treatment dilemma among both family physicians and dermatologists. The many treatment modalities documented in the literature have been for the most part unsuccessful or unacceptable. This report describes the use of phenoxybenzamine, an alpha-adrenergic antagonist, for control of excessive sweating in two patients. After a trial of topical medication, phenoxybenzamine is useful for the reduction of sweating to an acceptable level.
Paroxysmal localized hyperhidrosis is a rare sign of a disorder of the autonomic nervous system. It has been reported in association with peripheral nerve, spinal cord and hypothalamic lesions and in some cases the etiology is unidentified. We present 12 cases of idiopathic paroxysmal localized hyperhidrosis and discuss the therapeutic effect and possible mechanism of clonidine which is a specific central nervous system alpha 2--adrenergic receptor agonist.
Palmar hyperhidrosis can be a disabling condition in children. We report the results of transthoracic sympathectomy in 18 children aged 16 years or under. Follow-up, 1 to 11 years after surgery, revealed a high incidence of late sequelae, but these were not significant when compared to the primary condition. Transthoracic sympathectomy is recommended for children with severe palmar hyperhidrosis.
Ten patients with severe palmo-plantar hyperhidrosis have been treated successfully at home with tap water iontophoresis for a period not less than 6 months. The patients were asked to evaluate the treatment subjectively; 8 considered the results to have been good to very good. The same results were obtained in an objective evaluation by gravimetry, hygrometry and colorimetry. The full effects were seen after an average of 15 treatments of 20-30 min each. Through the new possibility of treating patients at home, therapy for palmo-plantar hyperhidrosis, which to date was only possible under medical supervision, has been simplified.
Idiopathic (primary) hyperhidrosis is a common and distressing condition. Excessive axillary sweating responds to local excision of the eccrine glands. In severe cases, sympathectomy may be indicated to deal with hyperhidrosis of the hands and feet. The surgical anatomy of transthoracic sympathectomy is described.
Radical sweat gland excision is the treatment of choice in axillary hyperhidrosis. After a review of the common surgical techniques the own technique is discribed. It consists of a vertical excision of the hyperhidrotic skin area and primary wound closure. No recurrences of hyperhidrosis were seen in the follow up period.
16 patients with palmar and/or plantar hyperhidrosis were treated with topically applied aluminium chloride hexahydrate in a 25% solution in absolute ethyl alcohol. Compared to treatment of axillary hyperhidrosis this formulation seems to be less effective, but a controlled study is needed. A simple method for transpiration measurement is described. It may be useful in daily practice to control the effect of the treatment.
New thoracoscopic methods have been reported to minimise the operative trauma after surgical treatment of primary hyperhidrosis of the palms. We therefore began with this minimally invasive technique for sympathetic ablation in 1990. Our first 81 patients presented here confirm earlier results of excellent effects, few complications and mild side-effects when treating palmar hyperhidrosis with thoracoscopic sympathectomy.
Thoracic sympathectomy is a very effective treatment of palmar hyperhidrosis. The described endoscopic technique has given good primary results in 99% of patients. After another session with this type of "minimal invasive surgery" 100% of the hands were satisfactorily dry. The hospital stay is just one post-operative day and the sick-leave is about a week. The drawbacks are minimal. Pain is tolerable and only eight patients needed a post-operative Bülau-drainage because of pneumothorax or bleeding. About 50% of patients experience a compensatory increased sweating of the trunk, but this is related to a warm environment and regulation of body temperature and seems to decrease with time. This technique makes it possible to treat all those suffering from palmar hyperhidrosis which can be a substantial, but underestimated handicap. To meet this kind of patient after a successful operation is extremely satisfying even for the surgeon. The post-operative wet and cold hand has immediately post-operatively become warm and dry.
Endoscopic transthoracic sympathectomy (ETS) has recently become established as a successful treatment for severe palmar and axillary hyperhidrosis. In this unit the indications for ETS have been broadened to include patients with Raynaud's syndrome and critical upper limb ischaemia and this paper is primarily concerned with analysing outcome in relation to the indication for operation. In all, 68 operations have been attempted in 40 patients and complete follow-up details are available on 62 treated limbs. One operation was a technical failure because of an obliterated pleural cavity. In the hyperhidrosis group (n = 28), all the affected areas showed symptomatic improvement at a median follow-up of 17 months. In the Raynaud's group (n = 30), 28 limbs (93%) were improved to some degree at the time of discharge, but at a median follow-up of 18 months only 15 limbs (50%) remained symtomatically improved to some degree. The four upper limbs treated for critical ischaemia were improved by ETS and no amputations were necessary. Significant postoperative chest pain was noted by nine patients (23%). There were three postoperative pneumothoraces, two intercostobrachial neuralgias and one transient Horner's syndrome. The cosmetic result was reported as excellent or good by 97% of patients. As with other forms of surgical thoracic sympathectomy, excellent early results are not maintained in the longer term when ETS is used to treat Raynaud's syndrome. Nevertheless, the greater simplicity and lower morbidity of the endoscopic method suggest that it can be offered to Raynaud's sufferers with greater impunity than open sympathectomies.
An 82-year-old man was referred to our pain clinic for the relief of pain arising from Pancoast tumor on the right side. The pain was controlled well by cervical epidural morphine, but one month after admission, he complained of unilateral hyperhidrosis on the face, head and neck on the left side. Massive sweating occurred only during the sleep. At this stage Horner's sign on the right side was recognized. Cervical epidural block diminished sweating. Massive sweating was observed until his death two months after admission. We speculate that paralysis of the right cervical sympathetic system caused by invasion of Pancoast tumor elicited sympathicotonia of the opposite side, resulting in left hemifacial hyperhidrosis, which was exaggerated during the sleep when the activity of perspiration center increased. We recommend that the presence of hemifacial sweating should be closely evaluated, because it can be caused not only by irritation of the ipsilateral sympathetic nervous system, but also by the paralysis of the contralateral sympathetic nervous system due to malignant tumors or other diseases in the neck and upper mediastinum.
Palmar hyperhidrosis (PH) is common in Orientals from subtropical areas. Many therapeutic modalities are used in practice, but none has proved to be entirely satisfactory. We have developed a new therapeutic technique by combining a video thoracoscopic system with a surgical laser unit (both waveguide CO2 laser and fibre-optic Nd:YAG laser). The operation was performed under general anaesthesia with alternative one-lung ventilation. With this technique, we are able to identify the sympathetic trunk on the TV screen and confirm its proper level with accurate ablation by intraoperative vasomotor monitoring. Consequently, an adequate sympathectomy can be definitely achieved through laser extirpation. We have successfully treated 300 PH patients with this technique from 1990 to 1992. The ages ranged from six to 63 years with a mean of 26.6. There were 125 males and 175 females. Most patients underwent en bloc ablation of the T2 segment which includes a major part of the T2 ganglion with its adjacent trunk which overlays the T2 rib head. All of them obtained a satisfactory relief of PH except 13 patients. The procedure did not result in a change of vital signs. There was neither obvious injury to lung nor bleeding. No Horner's syndrome was produced. The commonest complication was compensatory hyperhidrosis in various degrees encountered in about half of the cases. Two-thirds of the patients were followed up for more than 12 months and only three had recurrence. Based on our experience, the technique is considered to be a minor and safe procedure and able to achieve a definite and long-lasting therapeutic effect. It causes minimal discomfort and scarring. Particularly, the operation time and hospital stay were markedly shortened in comparison with other conventional open sympathectomy procedures.