1 Hyperhidrosis Dr Abbas Pardakhty 2011 Kerman Faculty
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Hyperhidrosis Dr Abbas Pardakhty 2011 Kerman Faculty of Pharmacy 2
Sweat Glands The human body has 2 -5 million sweat glands Two main types: ECCRINE APOCRINE Source: www. sweathelp. org 3
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 4
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 5
Sweating The hypothalamus serves as thermoregulatory center It controls both blood flow and sweat output to the skin’s surface Source: www. sweathelp. org 6
Sweating The hypothalamus can be triggered by: EXERCISE STRESS TEMPERATURE CHANGE HORMONES Source: www. sweathelp. org 7
Sweating Once triggered, the hypothalamus sends messages down the spinal cord via neurotransmitters. Source: www. sweathelp. org 8
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 9
Neurotransmitters act as “vehicles, ” transmitting information from the hypothalamus to the skin’s surface. 10 Photo used with permission: The Whiteley Clinic, 2007
Neurotransmitters The neurotransmitters can “exit” at various places along the spinal cord. The “exit” determines the location of skin innervation. 11
Spinal Cord Innervations T 2 -T 4 innervate the skin of the face T 4 -T 12 innervate the skin of the trunk Source: www. sweathelp. org 12 T 2 – T 8 innervate the skin of the upper limbs T 10 -T 12 innervate the skin of the lower limbs
Neurotransmitters Acetylcholine innervates Eccrine Sweat Glands Source: www. sweathelp. org 13 Catecholamines innervate Apocrine Sweat Glands
Sweating Once innervated, the apocrine and eccrine glands will produce …. Source: www. sweathelp. org SWEAT! 14
What is Hyperhidrosis? Sweating that is more than required to • maintain normal thermal regulation 15
Sweating Nomenclature Areas: Focal, regional, generalized Symmetry: Symmetric or asymmetric Classification: Primary vs. secondary Type of sweating: Anhidrosis, euhydrosis, hyperhidrosis • • 16 Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
Hyperhidrosis 17
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 • 18
Causes of Localized Hyperhidrosis Usually Idiopathic / Primary Social anxiety disorder Eccrine nevus Gustatory sweating Frey syndrome Impaired evaporation Stump hyperhidrosis after amputation 19 • •
Idiopathic (Primary) Focal Hyperhidrosis 20
Mean Age of Onset 21
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: 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. 22
Diagnostic Work-up History • Age of onset Location Trigger factors Review of symptoms – – Physical exam • Laboratory evaluation • Gravimetric – – Starch iodine test, with the darkened area 1° research tool showing location of excessive sweating Starch iodine – defines area of disease – 23
Axillary Sweat Production 346. 0 1° hyperhidrosis patients Hund et al. Arch Derm 2002; 138(4): 539 -41 healthy controls 24
DLQI Total Scores and Ranges by Dermatological Disease/Condition Diseases with DLQI Scores 10 or Greater Disease. DLQI Score (baseline) Hyperhidrosis palms 18– 8. 8 Hyperhidrosis axillary 17– 10 Eczema (inpatient)16. 2 Focal hyperhidrosis (general)15. 5– 9. 2 Psoriasis (inpatient)13. 9 Hyperhidrosis forehead 12. 5 Atopic eczema 12. 5– 5. 8 Psoriasis (outpatient)11. 9– 4. 51 Contact dermatitis 10. 8 Pruritus 10. 5– 10 Scores range from 0 to 30, with 30 indicating the worst quality of life. 25 Spalding et al. Value in Health 2003; 6(3): 242(abstract)
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 26
Treatment 27
Available Treatments Topical agents Iontopheresis Systemic agents anticholnergic – Botulinum toxin Surgery Local excision/currettage Thoracic sympathectomy 28 • • • – – • •
Treatment Response 29
Treatment Options Topical Click on the first treatment option to begin! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 30
Topical Treatment First line treatment Aluminum Chloride Hexahydrate antiperspirant of choice Most beneficial for axillary hyperhidrosis Can be used for plantar and palmar Hornberger, 2004 31 Photos used with permission: www. feelbest. com
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 32
Topical Treatment Sweat production never ceases, the gland is simply plugged Sweating will return as the skin undergoes regeneration or shedding Therefore…topical treatment is NOT a cure! Hornberger, 2004 33 Photo used with permission: Neurosurgical Medical Clinic, Inc
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 1 -3 weeks Hornberger, 2004 34
Topical Treatment: Pros and Cons – n No a v in e v i s Hornberger, 2004 35 Itch ing and at a bur ppl icat ning o f sk ion Tim in site & e-c ons um Tem ing & por ary reli ef
Topical Treatment: Effectiveness 88% effective for Axillary Hyperhidrosis 66. 6% stop using due to the “CONS” Naumann, Hamm, & Lowe, 2002 36
Treatment Options Topical Click on the second treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 37
Systemic Treatment Anticholinergics can be used in treating hyperhidrosis Most effective for cranio-facial hyerhidrosis Robinul – drug of choice Haider & Solish, 2004 38
Oral Glycopyrrolate (Glycopyrronium bromide) 39
How Does it Work? Anticholinergic Blocks Acetylcholine transmission Eccrine sweat glands no longer stimulated Sweat production ceases! Haider & Solish, 2004 40
Anticholinergics Long term therapy is required Major side effects: Dry mouth Dry eyes Constipation Blurred vision Difficulty with urination Thomas, Brown, & Vafaie, 2004 41
Anticholinergics Limited use in treating hyperhidrosis Only 21% effective 69. 7% stop using due to side effects Hamm, Naumann, & Kowalski, 2006 42
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 side-effects. Patients with diabetic gustatory sweating have also • noted a reduction in the frequency and severity of episodes after applying glycopyrronium 0. 5% cream 43
Treatment Options Topical Click on the third treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 44
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 45
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 46
Iontophoresis: Mechanism of Action + = ELECTRICTY WATER www. sweathelp. org 47 Thickening of skin And Blocked sweat flow
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 48
Treatment Options Topical Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 49
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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 51
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 52
BIOCHEMICAL PROCESS OF VESCICULAR FUSION BLOCKAGE 53
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 54
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 55
Treatment Options Topical Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 56
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 57
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 58
Local Excision Starch Iodine tests done post excision show • 80% - 90% decrease in sweating Has a potential for scarring • Eisenach, Atkinson, & Fealey, 2005 59
Treatment Options Topical Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 60
Endoscopic Thoracic Sympathectomy (ETS) Last treatment option PERMANENT Surgery performed under general anesthesia Haider & Solish, 2004 61
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 62
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 63
ETS Ganglion located along the sympathetic chain Ganglion formed below each rib Ganglion can be divided = sympathicotomy Ganglion can be removed = sympathectomy www. sweathelp. org 64 Photo used with permission: Neurosurgical Medical Clinic, Inc
ETS Ganglion at T 2 and T 3 = palmar hyperhidrosis Ganglion at T 3 and T 4 = axillary hyperhidrosis Ganglion at L 2 -L 4 = plantar hyperhidrosis www. sweathelp. org Photos used with permission: Neurosurgical Medical Clinic, Inc 65
ETS Cannot surgically excise or ablate L 2 -L 4 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 66
ETS Plantar hyperhidrosis resolves in 50% - 75% of cases when T 2 and T 3 are excised, though L 2 L 4 ganglion are never surgically treated Mechanism is unknown! Eisenach, Atkinson & Fealey, 2005 67
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 68
Horner’s Syndrome Stellate ganglion – fusion of C 8 and T 1 Innervates the face If Stellate ganglion is damaged, Horner’s Syndrome will occur May be mistaken for T 2 and T 3 May receive electrical current from cautery of T 2 and T 3 www. sweathelp. org 69
Horner’s Syndrome Signs and Symptoms Unilateral upper eyelid ptosis Pupil constriction Facial anhidrosis www. sweathelp. org 70
Treatment Option Review AXILLARY Hyperhidrosis PALMOPLANTAR Topical Treatment Botox Iontophoresis Local Excision Iontophoresis Botox ETS Hornberger, 2004 71
Treatment Option Review Systemic – blocks acetylcholine Photo used with permission: The Whiteley Clinic, 2007 72
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