Transcript Hyperhidrosis

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Hyperhidrosis
Dr Abbas Pardakhty
2011
Kerman Faculty of Pharmacy
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Sweat Glands
The human body has 2-5 million sweat
glands
Two main types:
ECCRINE
APOCRINE
Source: www.sweathelp.org
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Eccrine Sweat Glands
Approximately 3 million
eccrine sweat glands
Secrete a clear, odorless
fluid
Aid in regulating body
temperature
Areas of concentration:
Facial, plantar, and axillae
Source: www.sweathelp.org
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Apocrine Sweat Glands
Inactive until puberty
Produce thick fluid
Secretions come in
contact with bacteria on
the skin and produce
characteristic “body
odor”
Found in axillary and
genital areas
Source: www.sweathelp.org
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Sweating
The hypothalamus serves as the
thermoregulatory center
It controls both blood flow and sweat
output to the skin’s surface
Source: www.sweathelp.org
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Sweating
The hypothalamus can be triggered by:
EXERCISE
STRESS
TEMPERATURE CHANGE
HORMONES
Source: www.sweathelp.org
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Sweating
Once triggered,
the hypothalamus sends messages down the
spinal cord
via neurotransmitters.
Source: www.sweathelp.org
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Sweating
The neurostransmitters travel down the
spine via ganglion or sympathetic nerves
These ganglion travel to nerves, which
reach the skin’s surface
Source: www.sweathelp.org
Photo used with permission: The Whiteley Clinic,2007
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Neurotransmitters
Neurotransmitters act as “vehicles,” transmitting
information from the hypothalamus to the skin’s surface.
Photo used with permission:
The Whiteley Clinic, 2007
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Neurotransmitters
The neurotransmitters can “exit” at various
places along the spinal cord.
The “exit” determines the location of skin
innervation.
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Spinal Cord Innervations
T2-T4 innervate
the skin of the face
T4-T12 innervate the
skin of the trunk
T2 – T8 innervate the
skin of the upper limbs
T10-T12 innervate the skin
of the lower limbs
Source: www.sweathelp.org
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Neurotransmitters
Acetylcholine
innervates
Eccrine Sweat
Glands
Catecholamines
innervate
Apocrine Sweat
Glands
Source: www.sweathelp.org
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Sweating
Once innervated, the apocrine and eccrine
glands will produce ….
Source: www.sweathelp.org
SWEAT!
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What is Hyperhidrosis?
 Sweating that is more than
required to maintain normal
thermal regulation
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Sweating Nomenclature
 Areas: Focal, regional, generalized
 Symmetry: Symmetric or asymmetric
 Classification: Primary vs. secondary
 Type of sweating: Anhidrosis, euhydrosis,
hyperhidrosis
Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
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Hyperhidrosis
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Causes of Generalized Hyperhidrosis
Usually secondary in nature
 Drugs (Venlafaxine, ...), toxins, substance abuse
 Cardiovascular disorders
 Respiratory failure
 Infections
 Malignancies
 Hodgkin’s, myleoproliferative disorders, cancers with
increased catabolism
 Endocrine/metabolic disorders
 Thyrotoxicosis, pheochromocytoma, acromegaly, carcinoid
tumor, hypoglycemia, menopause
 Rarely Idiopathic / Primary HH
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Causes of Localized Hyperhidrosis
 Usually Idiopathic / Primary
 Social anxiety disorder
 Eccrine nevus
 Gustatory sweating
 Frey syndrome
 Impaired evaporation
 Stump hyperhidrosis after amputation
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Idiopathic (Primary) Focal Hyperhidrosis
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Mean Age of Onset
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Diagnosis of Primary
Focal Hyperhidrosis
 Focal, visible, excessive sweating of at least 6
months duration without apparent cause with at
least 2 of the following characteristics:
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•
•
•
•
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Bilateral and relatively symmetric
Impairs daily activities
Frequency of at least one episode per week
Age of onset less than 25 years
Positive family history
Cessation of focal sweating during sleep
Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
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Diagnostic Work-up
 History
•
•
•
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Age of onset
Location
Trigger factors
Review of symptoms
 Physical exam
 Laboratory evaluation
• Gravimetric –
1° research tool
• Starch iodine – defines area of disease
Starch iodine test, with the darkened area
showing location of excessive sweating
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Axillary Sweat Production
346.0
1° hyperhidrosis patients
Hund et al. Arch Derm 2002;138(4):539-41
healthy controls
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DLQI Total Scores and Ranges by Dermatological
Disease/Condition
Diseases with DLQI Scores 10 or Greater
Disease
DLQI Score (baseline)
Hyperhidrosis palms
Hyperhidrosis axillary
Eczema (inpatient)
Focal hyperhidrosis (general)
Psoriasis (inpatient)
Hyperhidrosis forehead
Atopic eczema
Psoriasis (outpatient)
Contact dermatitis
Pruritus
18–8.8
17–10
16.2
15.5–9.2
13.9
12.5
12.5–5.8
11.9–4.51
10.8
10.5–10
Scores range from 0 to 30, with 30 indicating the worst quality of life.
Spalding et al. Value in Health 2003;6(3):242(abstract)
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Summary
Primary Focal Hyperhidrosis is a
separate and unique disease
•Bilateral & symmetric
•Axilla, palms, soles, craniofacial
•Onset in childhood and adolescence
•Significant impact on quality of life
•Effective therapies
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Treatment
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Available Treatments
Topical agents
 Iontopheresis
 Systemic agents

•
anticholnergic
Botulinum toxin
 Surgery

•
•
Local excision/currettage
Thoracic sympathectomy
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Treatment Response
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Topical
Treatment Options
Click on the first treatment
option to begin!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Topical Treatment
First line treatment
Aluminum Chloride Hexahydrate
antiperspirant of choice
Photos used with permission:
www.feelbest.com
Most beneficial for axillary
hyperhidrosis
Can be used for plantar and palmar
Hornberger, 2004
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Topical Treatment:
How Does it Work?
The metal ions in the topical antiperspirant damage
the lining of the sweat gland.
As damage continues, a PLUG is formed over the
sweat gland.
www.sweathelp.org
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Topical Treatment
Sweat production never
ceases, the gland is simply
plugged
Sweating will return as the
skin undergoes
regeneration or shedding
Photo used with permission:
Neurosurgical Medical Clinic, Inc
Therefore…topical
treatment is NOT a cure!
Hornberger, 2004
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Topical Treatment:
How to Use
Best to apply before bedtime
Allow to remain on skin for 6 – 8 hours
Apply every 24 – 48 hours until sweating
diminishes
Maintenance applications needed every 13 weeks
Hornberger, 2004
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Topical Treatment:
Pros and Cons
Hornberger, 2004
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Topical Treatment:
Effectiveness
88% effective for
Axillary Hyperhidrosis
66.6% stop using due
to the “CONS”
Naumann, Hamm, & Lowe, 2002
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Topical
Treatment Options
Click on the second treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Systemic Treatment
Anticholinergics can be used in treating
hyperhidrosis
Most effective for cranio-facial hyerhidrosis
Robinul – drug of choice
Haider & Solish, 2004
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Oral Glycopyrrolate
(Glycopyrronium bromide)
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How Does it Work?
Anticholinergic
Blocks Acetylcholine transmission
Eccrine sweat glands no longer stimulated
Sweat production ceases!
Haider & Solish, 2004
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Anticholinergics
Long term therapy is required
Major side effects:
Dry mouth
Dry eyes
Constipation
Blurred vision
Difficulty with urination
Thomas, Brown, & Vafaie, 2004
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Anticholinergics
Limited use in treating
hyperhidrosis
Only 21% effective
69.7% stop using due
to side effects
Hamm, Naumann, & Kowalski, 2006
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Topical anticholinergics

glycopyrronium bromide as 1 and 2% cream or
roll-on solution
 Topical hyoscine as 0.25, 1, or 3% solution or
cream also gave control of sweating, but was
associated with a much higher incidence of sideeffects.
 Patients with diabetic gustatory sweating have
also noted a reduction in the frequency and
severity of episodes after applying
glycopyrronium 0.5% cream
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Topical
Treatment Options
Click on the third treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Iontophoresis
 Used
for palmar and
plantar hyperhidrosis
 Passage
of direct
electrical current onto
skin’s surface
 Device
can be purchased
for home use
Photo used with permission: Beast Psoriasis, 2006
Thomas, Brown, & Vafaie, 200 4
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Iontophoresis
Photo used with permission: Beat Psoriasis, 2006
Sit with hands or feet in
shallow tray of water
Allow 15 – 20 milli-amps of
electrical current to pass
through water
Use for 10 days, 30
minutes each day
Maintenance therapy
needed
Thomas, Brown, & Vafaie, 2004
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Iontophoresis:
Mechanism of Action
+
WATER
=
ELECTRICTY
Thickening of skin
And
Blocked sweat flow
www.sweathelp.org
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Iontophoresis
Side effects:
Skin irritation
Skin burns
Vesicle formation
Photo used with permission: Beat Psoriasis, 2006
Time consuming treatment
80% effective for palmar and/or plantar
hyperidrosis
Thomas, Brown, and Vafaie, 2004
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Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Botox
Botox injections can be used to treat
axillary, palmar, and plantar hyperhidrosis
Analgesic applied prior to injection
Nerve block applied to ulnar or radial
nerve prior to palmar injection
Haider & Solish, 2004
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Botox
Botox blocks the release of acetylcholine
at the site of the neuromuscular junction.
Sweat glands are not stimulated,
and sweat production ceases
Photo used with permission: Whiteley Clinic, 2007
Site of blockage
Haider & Solish, 2004
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BIOCHEMICAL PROCESS OF
VESCICULAR FUSION BLOCKAGE
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Botox
Starch Iodine test
done prior to injection
Delineates areas of
excess sweating with
black-purple
discoloration of the
skin
Photo used with permission:
Eisenach, Atkinson, & Fealey, 2005
Haider & Solish, 2004
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Botox
Pros:
Lasts 6-7 months
90% effective
Cons:
Very painful to the
palms and soles of
feet
Expensive: $1400$1600 per treatment
Thomas, Brown, & Vafaie, 2004
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Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Local Excision
Used only for axillary
hyperhidrosis
Starch Iodine test done prior to
excision
Performed under local
anesthesia
Vasoconstrictor applied to
axillary region
Small incisions made
Photo used with permission:
Gasparri, 2006
Eisenach, Atkinson, Foley, 2005
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Local Excision
Eccrine sweat glands removed through:
Liposuction – suctioned out
Curettage – scraped out
Excision – cut out
Incisions sutured
Pain and bruising to excision site
Photo used with permission:
Gasparri, 2006
Eisenach, Atkinson, & Fealey, 2005
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Local Excision
 Starch
Iodine tests done post excision
show 80% - 90% decrease in sweating
 Has
a potential for scarring
Eisenach, Atkinson, & Fealey, 2005
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Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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Endoscopic Thoracic
Sympathectomy (ETS)
Last treatment option
PERMANENT
Surgery performed under general
anesthesia
Haider & Solish, 2004
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ETS
Goal of surgery is to excise or ablate the
ganglion that innervate the sweat glands
Performed most frequently for palmar
hyperhidrosis
Performed through
thorascope or video
Minimally invasive
Han, Oren, & Gottfried, 2002
Photo used with permission:
Neurosurgical Medical Clinic, Inc
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ETS
Small incision made laterally under each
axilla
Incision made through intercostal space
Surgery can be performed on outpatient
basis
However, some patients remain in hospital
for one night
Han, Oren, & Gottfried, 2002
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ETS
Ganglion located along
the sympathetic chain
Ganglion formed below
each rib
Ganglion can be divided
= sympathicotomy
Ganglion can be
removed =
sympathectomy
Photo used with permission:
Neurosurgical Medical Clinic, Inc
www.sweathelp.org
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ETS
Ganglion at T2 and T3 = palmar
hyperhidrosis
Ganglion at T3 and T4 = axillary
hyperhidrosis
Ganglion at L2-L4 = plantar hyperhidrosis
www.sweathelp.org
Photos used with permission:
Neurosurgical Medical Clinic, Inc
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ETS
Cannot surgically excise or ablate L2-L4
for plantar hyperhidrosis due to sexual
side effects
95% success rate in curing palmar
hyperhidrosis
Success rates slightly lower for axillary
hyperhidrosis
Eisenach, Atkinson, & Fealey, 2005
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ETS
Plantar hyperhidrosis resolves in 50% 75% of cases when T2 and T3 are
excised, though L2-L4 ganglion are never
surgically treated
Mechanism is unknown!
Eisenach, Atkinson & Fealey, 2005
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ETS: Side Effects
Surgical complications:
Hemo-pneumothorax requiring chest tube
placement – 1%
Atelectasis (collapse of the lung)
Intercostal neuralgia – 1%
Horner’s Syndrome – 1%
Compensatory Sweating – 60%
Eisenach, Atkinson, & Fealey, 2005
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Horner’s Syndrome
Stellate ganglion – fusion of C8 and T1
Innervates the face
If Stellate ganglion is damaged, Horner’s
Syndrome will occur
May be mistaken for T2 and T3
May receive electrical current from cautery of
T2 and T3
www.sweathelp.org
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Horner’s Syndrome
Signs and Symptoms
Unilateral upper eyelid ptosis
Pupil constriction
Facial anhidrosis
www.sweathelp.org
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Treatment Option Review
AXILLARY
Hyperhidrosis
PALMOPLANTAR
Topical Treatment
Botox
Iontophoresis
Local Excision
Iontophoresis
Botox
ETS
Hornberger, 2004
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Treatment Option Review
Systemic – blocks
acetylcholine
Photo used with permission: The Whiteley Clinic, 2007
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