Download Axillary Hyperhydrosis

Hyperhidrosis
Hyperhidrosis is a pathologic condition characterized by the secretion of sweat in
excess to the normal physiologic needs of the body
Pathophysiology



Two types of sweat glands, the eccrine and the apocrine, situated near the hair
follicles in the lower dermis and upper subcutaneous fat of the human axilla.
Eccrine glands
o distributed evenly throughout the skin(except vermillion, labia minora,
glans, prepuce)
o greatest density of glands found in the axilla, palm, and sole of the foot.
o produce clear, hypotonic excretions and are known for their role in
hyperhidrosis.
o primary function of sweat secretion is thermoregulation
o also maintenance of the health and texture of the skin, with moisture
lending traction to the skin surface
o regulation of the rate and volume of sweat production is normally
controlled by the hypothalamus;
o sympathetic signal leads to increase in sweat secretion - carried through
postganglionic cholinergic fibers
Apocrine gland located primarily in the axilla, the areola of the breasts, and the
anogenital region. Overactivity leads to osmidrosis (axillary bromidrosis)
o responsible for producing the malodor and staining of clothing with its
milky secretion. The offensive odour is believed to have resulted from the
decomposition of fatty acid contained in the apocrine sweat gland by
bacteria
o difference between osmidrosis and bromidrosis is the degree of odor and
quantity of sweat
Causes
1) Primary – idiopathic
2) Secondary – febrile illness, metabolic disorders, medications
Classification
1) Primary - Essential hyperhidrosis (1% of population)
a. emotionally induced - in which it affects the palms/soles(40%),
axillae(40%) and face (10%)
b. associated with sympathetic overactivity
2) Secondary
a. localized
i. disruption followed by abnormal regeneration of sympathetic
nerves or a localized abnormality in the number or distribution
of the eccrine glands, or it may be associated with other
(usually vascular) abnormalities.
ii. Gustatory stimuli (Frey syndrome)
b. generalized
i. endocrine disease (hypoglycemia, hyperthyroidism)
ii. neurologic disorders(syringomyelia, focal lesions of the central
nervous system)
iii. drug use (antidepressants, antiemetics),
iv. menopause
v. neoplastic disease (Hodgkin lymphoma, carcinoid tumors,
pheochromocytoma),
vi. chronic infection
Quantification
1) Minor's iodine starch test
o involves wiping the skin with an antibacterial iodine solution that is
allowed to dry and then dusting the skin with a cornstarch powder.
o As sweat reaches the skin surface – it dissolves starch. A reaction
between the iodine and starch produces a colorimetric reaction as the
cornstarch powder turns deep purple. The magnitude of the sweat area
can then be photographed and measured
o Useful in pinpointing recurrence after surgery
2) gravimetry
o filter paper is weighed dry on a high-precision laboratory scale, then
placed in contact with a hyperhidrotic area of patient skin for 60
seconds, then weighed again.
o Rate of sweat production in hyperhidrotic areas near 200 mg/min.
3) ninhydrin test
o ninhydrin solution sprayed on an air-dried axilla, relying on color
reaction with proteinaceous sweat to produce a visible pattern.
 Mapping is not so useful for primary excision since area corresponds to hair
bearing skin – more useful in areas of recurrence.
Treatment
Strategy
Medical
 topical therapies
o aluminium chloride in anhydrous ethyl alcohol is usually the most
effective topical agent
o others: topical anticholinergics, boric acid, 2-5% tannic acid solutions,
resorcinol, potassium permanganate, formaldehyde
o disadvantages – short term effect, skin irritation, skin staining with tannic
acid and glutaraldehyde
 systemic medications
o anticholinergics - propantheline bromide, glycopyrolate (does not cross
blood brain barrier like atropine), oxybutynin, and benztropine.
Unappealing because their adverse effect profile includes mydriasis, blurry
vision, dry mouth and eyes, acute glaucoma, difficulty with micturition,
constipation, nausea, vomiting, giddiness, tachycardia, palpitations, and
arrhythmias.
o Benzodiazepine to reduce anxiety
o indomethacin, and calcium channel blockers
o
 Iontophoresis
o defined as topical introduction of ionized drugs into the skin using direct
current.
o Mechanism not known ? cause a temporary blockage of the sweat duct at
the level of the stratum corneum
o daily treatment (average of 15) of each palm or sole for 30 minutes at 1520 mA using tap water iontophoresis found to be effective
o treatment with anticholinergic iontophoresis is more effective than tap
water iontophoresis


o Good results are achievable, especially for the treatment of the palm and
plantar areas, but the treatment is less successful for the axilla.
o Complications of treatment are generally mild and may include erythema
of the treated skin, transient vesicular rash, and transient paresthesia
o Contraindications to treatment include the presence of cardiac pacemakers,
pregnancy, or metal orthopedic implants.
Radiation
o Low-dose superficial radiation has been used for hidradenitis
o Long term side effects make this unappealing
Botox injections
a. Axillary
 Intradermal injection
 NEJM (Heckmann Feb 2001)
1. double blind n=145
2. 200U in 1 axilla, placebo in the other
3. 6x reduction in sweat production; 2.5x reduction at 6
months
 Arch Dermatol (Naumann 2003)
4. 50U each axilla
5. ≥50% reduction in axillary sweating
6. responders 82% botox vs 21% placebo
 Arch Dermatol (2005)
7. Randomised side by side study
8. 100U equally effective as 200U
 Generally 50U used each side (1-2U/cm2)
 Map with starch iodine
 injections are spaced 1 to 2.5 cm apart
 expect sweating reduction of between 70 and 80 percent
 Complications minor - hematoma
b. Palmar
 Intradermal injection
 50-100units into 20 sites in each palm
 26% reduction in sweat production after 3 and 8 weeks and a 31%
reduction after 13 weeks.
 Long duration of anhydrosis 4-12 months (? Structural changes in
sweat glands)
 May be complicated by intrinsic muscle weakness
 median/ulnar nerve blocks often required for pain control
Surgical
 Reduce sympathetic outflow
1. Thorascopic sympathectomy (open or endoscopic)
 Avoid in patients with axillary hyperhidrosis only
 Best for palms (90-98%)
 T2-T4 excised usually
 T1 – facial hyperhidrosis
 T2-T3 – palmar
 T4, T5 - axillary


Complications
 Horner’s syndrome
 Pneumothorax/hemothorax
 Thoracic duct injury
 phrenic nerve damage
 death
 compensatory sweating (induction of sweating in
previously unaffected areas of the body – up to 50%) –does
not occur after Skoog adenectomy
 gustatory sweating (33%)
 Permanent nonfunction of the eccrine glands following
sympathectomy may lead to hyperkeratosis, scaling, and
fissuring of the skin
Subcutaneous excision
Subcutaneous excision
1. Open excision - Skoog procedure (1962)
a. First operation described for axillary hyperhidrosis
Classic Skoog
Modified Skoog
b. Transverse limb from anterior axillary fold to posterior extent of hair
bearing skin. Flaps are everted and the layer of the glands snipped off
the undersurface of the dermis.
c. 80-90% success in reduction
d. Some use CO2 to vaporise the glands to reduce complications but also
less effective
e. Disadvantages:
i. hematoma, seroma, infection, noticeable scar, scar contracture,
alopecia, wound dehiscence, skin flap necrosis, and a long
immobilization time.
2. Liposuction
a. Suction assisted or ultrasonic
b. A small-bore liposuction cannula is used, with the suction opening
turned toward the underside of the skin
c. Work by curettage - damaging glands or disrupting neural supply
d. Not as effective as open surgery but less complications – 3% vs 11%
(PRS 2004)
e. Tried for hidradenitis but not effective
f. High recurrence rate - reinnervation and/or gland regeneration
g. Ultrasonic aspiration gives better results such as shorter surgical scar
(1 vs 3 ports) and relatively low recurrence rate, but more surgical
complications.
h. Complications – skin necrosis, perforations, alopecia (transient),
recurrence