HYPERHIDROSIS: A Comprehensive Review Dina Hamadi, R.N., B.S.N. Alverno College: Alverno College: Master’s of Science in Nursing

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Objectives Understand the pathophysiology of sweating Identify diagnostic criteria for Hypherhidrosis Identify treatment options for the Hyperhidrosis patient

Choose the Topic! Sweat glands Sweat glands What makes me sweat? What makes me sweat? What is Hyperhidrosis? What is Hyperhidrosis? Treatment Options Treatment Options

Sweat Glands The human body has 2-5 million sweat glands Two main types: Click on the different sweat gland types to learn more! ECCRINE APOCRINE Click the “Home” button after viewing both types Source:

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 CLICK HERE Source:

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 CLICK HERE Source:

Sweating The hypothalamus serves as the thermoregulatory center The hypothalamus serves as the thermoregulatory center It controls both blood flow and sweat output to the skin’s surface It controls both blood flow and sweat output to the skin’s surface Source:

Sweating The hypothalamus can be triggered by: The hypothalamus can be triggered by: EXERCISE TEMPERATURE CHANGE STRESS HORMONES Source:

Sweating Once triggered, the hypothalamus sends messages down the spinal cord via neurotransmitters. Source:

Sweating The neurostransmitters travel down the spine via ganglion or sympathetic nerves These ganglion travel to nerves, which reach the skin’s surface Photo used with permission: The Whiteley Clinic,2007 Source:

Neurotransmitters Neurotransmitters act as “vehicles,” transmitting information from the hypothalamus to the skin’s surface. 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.

Spinal Cord Innervations T2 – T8 innervate the skin of the upper limbs T2-T4 innervate the skin of the face T4-T12 innervate the skin of the trunk T10-T12 innervate the skin of the lower limbs Source:

Neurotransmitters Acetylcholine innervates Eccrine Sweat Glands Catecholamines innervate Apocrine Sweat Glands Source:

Sweating Once innervated, the apocrine and eccrine glands will produce …. SWEAT! SWEAT! Click on the picture to take the “Sweating Quiz” Click on the “Home” button to return to the topic choices Source:

Question 1 What serves as the body’s thermoregulatory center? a. The hypothalamus The hypothalamus The hypothalamus b. The adrenal cortex The adrenal cortex The adrenal cortex c. The frontal lobe The frontal lobe The frontal lobe

CONGRATULATIONS! The hypothalamus regulates sweat output and blood flow to the skin’s surface! Take me to question 2!

SORRY….TRY AGAIN! What regulates blood flow and sweat output to the skin’s surface?  The hypothalamus The hypothalamus The hypothalamus  The adrenal cortex The adrenal cortex The adrenal cortex  The frontal lobe The frontal lobe The frontal lobe

Question 2 What neurotransmitter innervates eccrine sweat glands? a. Acetylcholine Acetylcholine b. Catecholamine Catecholamine c. Glucose Glucose

You’re Right!! Take me to question 3!

Try Again! Hint: Catecholamines innervate apocrine sweat glands! Let me try question 2 again!

Question 3 The hypothalamus can be triggered by all these except: a. Stress Stress b. Exercise Exercise c. Obesity Obesity d. Temperature change Temperature change Temperature change

CORRECT!! You have successfully completed this section of the tutorial. Return home!

Try Again! Return to question 3! Return to question 3!

Hyperhidrosis Hyperhidrosis is a state of excessive sweating of the axilla, palms, soles, or face that interferes with daily activities Haider & Solish, 2004 Photo used with permission: University of Miami Cosmetic Center, 2007

Two Types  Primary or idiopathic  Secondary: Resulting from respiratory/heart failure, malignancy, drug/alcohol abuse, malignancy, drug/alcohol abuse, hyperthyroidism, infection hyperthyroidism, infection Haider & Solish, 2004

Fun Facts Diagnosed in 2.8% of the U.S. population 70% of those with symptoms do not consult a physician Peaks in early adulthood Haider & Solish, 2004

Diagnostic Criteria: Primary Hyperhidrosis MUST HAVE 1. Focal, visible, excessive sweating 2. 6 months duration 3. No apparent cause TWO OR MORE: 1. Bilateral and symmetric sweating 2. Impairment of daily activities 3. At least one episode per week 4. Onset of less than 25 years 5. Positive family history Hornberger, 2004

What is Hyperhidrosis? Involves the eccrine sweat glands, however: Sweat glands are NORMAL No change in size No change in shape No change in number Haider & Solish, 2004

Cause Exact cause is unknown Familial or genetic? Familial or genetic? Excessive Sympathetic Activity? Click on the raindrops to learn more about this theory!

Excessive Sympathetic Activity The eccrine sweat glands are excessively stimulated by acetylcholine Increased SWEAT production Hornberger, 2004

Excessive Sympathetic Activity Because the sweat glands are continuously stimulated, they are stuck in the position Hornberger, 2004

QUIZ TIME! Those diagnosed with hyperhidrosis have abnormal eccrine sweat glands. TRUE FALSE

GOOD JOB! The sweat glands are normal, with no variance in size, shape, or number! Take me to Question 2!

SORRY! Try again…. Click on the sad face to try again!

Question 2 Hyperhidrosis involves which sweat gland type? Apocrine Eccrine

Oops! Take me back to the question! Take me back to the question!

YES!! Hyperhidrosis involves the eccrine sweat glands! You have successfully completed this section of the tutorial. You may return Home!

Treatment Options Rules to Follow: Different treatment for areas affected Always start with least invasive treatment option

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the first treatment option to begin!

Topical Treatment First line treatment Aluminum Chloride Hexahydrate antiperspirant of choice antiperspirant of choice Most beneficial for axillary hyperhidrosis Can be used for plantar and palmar Photos used with permission: Hornberger, 2004

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.

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 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

Topical Treatment: Pros and Cons Non – invasive Itching and burning of skin at application site & Time-consuming & Temporary relief Hornberger, 2004

Topical Treatment: Effectiveness 66.6% stop using due to the “CONS” Naumann, Hamm, & Lowe, % effective for Axillary Hyperhidrosis

QUICK REVIEW! Fill in the Blank! Topical Treatments work by ________ sweat glands. Destroying Plugging Melting

That’s Right! Topical Treatments PLUG the sweat gland Take me to the next treatment option!

Sorry! HINT: Sweat production never stops, the output is simply blocked! Take me back to the question!

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the second treatment option!

Systemic Treatment Anticholinergics can be used in treating hyperhidrosis Most effective for cranio-facial hyerhidrosis Robinul – drug of choice Haider & Solish, 2004

How Does it Work? Anticholinergic Blocks Acetylcholine transmission Eccrine sweat glands Eccrine sweat glands no longer stimulated Sweat production ceases! Haider & Solish, 2004

Anticholinergics Long term therapy is required Major side effects: Dry mouth Dry eyes Constipation Blurred vision Difficulty with urination Thomas, Brown, & Vafaie, 2004

Anticholinergics Limited use in treating hyperhidrosis Only 21% effective 69.7% stop using due to side effects Hamm, Naumann, & Kowalski, 2006

Review Anticholinergics block transmission of ? a. Catecholamines Catecholamines b. Epinephrine Epinephrine c. Acetylcholine Acetylcholine

Yes!! Acetylcholine transmission is blocked! Take me to the next treatment option!

Sorry! Click on the picture to try again!

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the third treatment option!

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

Iontophoresis 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 Photo used with permission: Beat Psoriasis, 2006 Thomas, Brown, & Vafaie, 2004

Iontophoresis: Mechanism of Action WATER + ELECTRICTY = Thickening of skin And Blocked sweat flow

Iontophoresis Side effects: Skin irritation Skin burns Vesicle formation Time consuming treatment 80% effective for palmar and/or plantar hyperidrosis Photo used with permission: Beat Psoriasis, 2006 Thomas, Brown, and Vafaie, 2004

Iontophoresis Contraindicated in those: 1. Who are pregnant 2. Have pacemakers 3. Have metal implants 4. Have cardiac conditions 5. Have epilepsy

Question…. Iontophoresis is NOT used in treating which type of hyperhidrosis? a. Palmar Palmar b. Axillary Axillary c. Plantar Plantar

Yes! Iontophoresis can be used in treating Palmar and/or Plantar hyperhidrosis Take me to the next treatment option

HINT: Look at these pictures…. Try Again! Click on either picture to Try again! Photos used with permission: Beat Psoriasis, 2006

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the fourth treatment option!

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

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

Botox Botox blocks the release of acetylcholine at the site of the neuromuscular junction. Sweat glands are not stimulated, and sweat production ceases Site of blockage Photo used with permission: Whiteley Clinic, 2007 Haider & Solish, 2004

Botox Cons: Very painful to the palms and soles of feet Expensive: $1400- $1600 per treatment Pros: Lasts 6-7 months 90% effective Thomas, Brown, & Vafaie, 2004

Quick Review A Starch-Iodine test is done prior to botox injection. True False

Correct! This test highlights areas of excessive sweating! Take me to the next treatment option

Try Again! Hint: The test gives a “map,” highlighting areas of excessive sweating Click on the picture to try again! Click on the picture to try again!

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the fourth treatment option!

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 Eisenach, Atkinson, Foley, 2005 Photo used with permission: Gasparri, 2006

Local Excision Eccrine sweat glands removed through: Liposuction – suctioned out Curettage – scraped out Excision – cut out Incisions sutured Pain and bruising to excision site Eisenach, Atkinson, & Fealey, 2005 Photo used with permission: Gasparri, 2006

Local Excision  Starch Iodine tests done post excision show 80% - 90% decrease in sweating  Has a potential for scarring Eisenach, Atkinson, & Fealey, 2005

Review! Local Excision is used for what type of hyperhidrosis? a. Plantar Plantar b. Palmar Palmar c. Axillary Axillary

Correct! Local Excision is used for axillary hyperhidrosis! Take me to the next treatment option!

Try Again! Click on the picture to try again!

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Click on the fourth treatment option!

Endoscopic Thoracic Sympathectomy (ETS) Last treatment option PERMANENT Surgery performed under general anesthesia Haider & Solish, 2004

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 Photo used with permission: Neurosurgical Medical Clinic, Inc Han, Oren, & Gottfried, 2002

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

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

ETS Ganglion at T2 and T3 = palmar hyperhidrosis Ganglion at T3 and T4 = axillary hyperhidrosis Ganglion at L2-L4 = plantar hyperhidrosis Photos used with permission: Neurosurgical Medical Clinic, Inc

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

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

ETS: Side Effects Surgical complications: Hemo-pneumothorax requiring chest tube placement – 1% Atelectasis Intercostal neuralgia – 1% Horner’s Syndrome – 1% Compensatory Sweating – 60% Eisenach, Atkinson, & Fealey, 2005

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

Horner’s Syndrome Signs and Symptoms Unilateral upper eyelid ptosis Pupil constriction Facial anhidrosis

Compensatory Sweating Most frequent complication – 60% of post-op patients Severe sweating noted to abdomen, chest, back, and thighs More severe for those who live in a hot climate Photo used with permission: ETS Discussion Forum and Reversals, 2005

Compensatory Sweating Mechanism poorly understood Theory states: After excision of T2 and T3, 40% of body’s sweat function is lost Body tries to compensate for this loss Andrews & Rennie, 1997 Photo used with permission: ETS Discussion Forum and Reversals, 2005

Compensatory Sweating Most patients feel compensatory sweating is a minor draw-back to surgery Sweating to abdomen/trunk = less interference with daily activities Able to write/handle objects Gossot, Galetta, & Pascal, 2003 Photo used with permission: ETS Discussion Forum and Reversals, 2005

Let’s Review ETS is performed most often for what type of hyperhidrosis: a. Axillary Axillary b. Palmar Palmar c. Plantar Plantar

CORRECT! ETS is performed for palmar hyperhidrosis! Take me to the next question!

TRY AGAIN! Click on the picture to try again!

Question 2 What is the most significant side effect of ETS? a. Hemo-pneumothorax Hemo-pneumothorax b. Horner’s Syndrome Horner’s Syndrome Horner’s Syndrome c. Compensatory Sweating Compensatory Sweating Compensatory Sweating

That’s Right! Compensatory Sweating can occur in 60% of post-op patients! Take me to the next activity!

Sorry! Horner’s Syndrome and Hemo- pneumothorax only occur in 1% of the cases! Click on the face to try again! Click on the face to try again!

Treatment Option Review Hyperhidrosis Topical Treatment Botox Iontophoresis Local Excision Iontophoresis Botox ETS AXILLARY PALMOPLANTAR Hornberger, 2004

Treatment Option Review Photo used with permission: The Whiteley Clinic, 2007 Systemic – blocks acetylcholine

CONGRATUALTIONS!! YOU HAVE SUCCESSFULLY COMPLETED THIS TUTORIAL!!

References Andrews, B. T. & Renni, J. A. (1997). Predicting changes in the distribution of sweating following thorascopic sympathectomy. The British Journal of Surger, 84(12), Beat Psoriasis. (2006). What is hyperhidrosis or excessive sweating? Retrieved March 22, 2007, from Canada’s Largest Online Health and Beauty Aids. (n.d.). Retrieved April 12, 2007, from Eisenach, J., Atkinson, J., & Fealey, R. (2005). Hyperhidrosis: Evolving therapies for a well-established phenomenon. Mayo Clinic Proceedings, 80(5), ETS Discussion Forum and Reversals. (2005). Compensatory sweating after ets. Retrieved March 22, 2007, from D=1.topic D=1.topic D=1.topic Gasparri, M. (2006). Photography, Medical College of Wisconsin. Gossot, D., Galetta, D., & Pascal, A. (2003). Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. The Society of Thoracic Surgeons, 75, Haider, A. & Solish, N. (2004). Hyperhidrosis: An approach to diagnosis and management. Dermatology Nursing, 16(6),

References Hamm, H., Naumann, M., & Kowalski, J. (2006). Primary focal hyperhidrosis: Disease characteristics and functional impairment. Dermatology, Hornberger, J. (2004). Recognition, diagnosis, and treatment of primary focal hyperhidrosis. Journal of the American Academy of Dermatology, 51(2), International Hyperhidrosis Society. (2007). About hyperhidrosis: Physiology of normal sweating. Retrieved March 7, 2007, from Naumann, M. K., Hamm, H., & Lowe, J. (2002). Effects of botulinim toxin type A on quality of life measures in patients with excessive axillary sweating: A randomized controlled trial. British Journal of Dermatology, 147, Neurosurgical Medical Clinic, Inc. (n.d.). Neurosurgical Diseases: Hyperhidrosis. Retrieved March 23, 2007, from neurosurgeon.com/diseases/hyperhidrosis.html. Thomas, I., Brown, J. & Vafaie, J. (2004). Palmoplantar hyperhidrosis: A therapeutic challenge. American Family Physician, 69(5,) Unatrributed Clip Art: Microsoft Office, University of Miami Cosmetic Center. (2007). Botox for Hyperhidrosis. Retrieved April 10, 2007, from Whiteley Clinic. (2007). The latest treatment in excessive sweating. Retrieved April 2, 2007, from