hyperhidrosis,a comprehensive view

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HYPERHIDROSIS: A Comprehensive Review:

HYPERHIDROSIS: A Comprehensive Review Dr Rida Akmal PGR Dermatology Department DHQ Hospital Faisalabad

Objectives:

Objectives To understand the pathophysiology of sweating Identify diagnostic criteria for Hypherhidrosis Identify treatment options for the Hyperhidrosis patient 10/5/2012 2 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

Sweat glands What makes sweat? What is Hyperhidrosis ? Treatment Options 10/5/2012 3 Dr. Rida Akmal DHQ Hospital Fsd

Sweat Glands:

Sweat Glands The human body has 2-5 million sweat glands Two main types: ECCRINE APOCRINE 10/5/2012 4 Dr. Rida Akmal DHQ Hospital Fsd

Eccrine Sweat Glands:

Eccrine Sweat Glands Approximately 3 million eccrine sweat glands Secrete a clear, odorless fluid Help in regulating body temperature Areas of concentration: Facial, plantar, and axillae 10/5/2012 5 Dr. Rida Akmal DHQ Hospital Fsd

Apocrine Sweat Glands:

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 10/5/2012 6 Dr. Rida Akmal DHQ Hospital Fsd

Sweating :

Sweating The hypothalamus serves as the thermoregulatory center It controls both blood flow and sweat output to the skin’s surface 10/5/2012 7 Dr. Rida Akmal DHQ Hospital Fsd

Sweating:

Sweating The hypothalamus can be triggered by: EXERCISE TEMPERATURE CHANGE STRESS HORMONES 10/5/2012 8 Dr. Rida Akmal DHQ Hospital Fsd

Sweating:

Sweating Once triggered, the hypothalamus sends messages down the spinal cord via nerve signals. 10/5/2012 9 Dr. Rida Akmal DHQ Hospital Fsd

Sweating:

Sweating The neurostransmitters travel down the spine via ganglion or sympathetic nerves These ganglion travel to nerves, which reach the skin’s surfacec 10/5/2012 10 Dr. Rida Akmal DHQ Hospital Fsd

Neurotransmitters:

Neurotransmitters Neurotransmitters act as “vehicles,” transmitting information from the hypothalamus to the skin’s surface. Photo used with permission: The Whiteley Clinic, 2007 10/5/2012 11 Dr. Rida Akmal DHQ Hospital Fsd

Neurotransmitters:

Neurotransmitters The neurotransmitters can “exit” at various places along the spinal cord. 10/5/2012 12 Dr. Rida Akmal DHQ Hospital Fsd

Spinal Cord Innervations:

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 10/5/2012 13 Dr. Rida Akmal DHQ Hospital Fsd

Neurotransmitters:

Neurotransmitters Acetylcholine innervates Eccrine Sweat Glands Catecholamines innervate Apocrine Sweat Glands 10/5/2012 14 Dr. Rida Akmal DHQ Hospital Fsd

Sweating:

Sweating Once innervated, the apocrine and eccrine glands will produce …. SWEAT! 10/5/2012 15 Dr. Rida Akmal DHQ Hospital Fsd

Question 1:

Question 1 What serves as the body’s thermoregulatory center? The hypothalamus The adrenal cortex The frontal lobe 10/5/2012 16 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

CONGRATULATIONS! The hypothalamus regulates sweat output and blood flow to the skin’s surface! 10/5/2012 17 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

SORRY….TRY AGAIN! What regulates blood flow and sweat output to the skin’s surface? The hypothalamus The adrenal cortex The frontal lobe 10/5/2012 18 Dr. Rida Akmal DHQ Hospital Fsd

Question 2:

Question 2 What neurotransmitter innervates eccrine sweat glands? Acetylcholine Catecholamine Glucose 10/5/2012 19 Dr. Rida Akmal DHQ Hospital Fsd

You’re Right!!:

You’re Right!! 10/5/2012 20 Dr. Rida Akmal DHQ Hospital Fsd

Try Again!:

Try Again! Hint: Catecholamines innervate apocrine sweat glands! 10/5/2012 21 Dr. Rida Akmal DHQ Hospital Fsd

Question 3:

Question 3 The hypothalamus can be triggered by all these except : Stress Exercise Obesity Temperature change 10/5/2012 22 Dr. Rida Akmal DHQ Hospital Fsd

CORRECT!!:

CORRECT!! 10/5/2012 23 Dr. Rida Akmal DHQ Hospital Fsd

Try Again!:

Try Again! 10/5/2012 24 Dr. Rida Akmal DHQ Hospital Fsd

Sweating Nomeculture :

Sweating Nomeculture 10/5/2012 25 Dr. Rida Akmal DHQ Hospital Fsd Areas: Focal, regional, generalized Symmetry: Symmetric or asymmetric Classification: Primary vs. secondary Type of sweating: Anhidrosis , euhydrosis , hyperhidrosis

Hyperhidrosis:

Hyperhidrosis Hyperhidrosis is a state of excessive sweating of the axilla, palms, soles, or face that interferes with daily activities 10/5/2012 26 Dr. Rida Akmal DHQ Hospital Fsd

Hyperhydrosis:

Hyperhydrosis 10/5/2012 27 Dr. Rida Akmal DHQ Hospital Fsd Qualitative definition is subjective Quantitative definition for research is production of more than 100ml of sweat in 1 axilla over 5 minutes

PowerPoint Presentation:

10/5/2012 28 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

29 Causes of Generalized Hyperhidrosis Usually secondary in nature Drugs, toxins, substance abuse Cardiovascular disorders Respiratory failure Infections Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

Malignancies Hodgkin’s, myleoproliferative disorders, cancers with increased catabolism Endocrine/metabolic disorders Thyrotoxicosis, pheochromocytoma, acromegaly, carcinoid tumor, hypoglycemia, menopause rarely Idiopathic 10/5/2012 30

PowerPoint Presentation:

31 Causes of Localized Hyperhidrosis Usually Idiopathic / Primary Social anxiety disorder Eccrine nevus Gustatory sweating Frey syndrome Impaired evaporation Stump hyperhidrosis after amputation Dr. Rida Akmal DHQ Hospital Fsd

Two Types:

Two Types Primary or idiopathic Secondary : Resulting from respiratory/heart failure, malignancy, drug/alcohol abuse, hyperthyroidism, infection 10/5/2012 32 Dr. Rida Akmal DHQ Hospital Fsd

Fun Facts:

Fun Facts 70% of those with symptoms do not consult a physician Peaks in early adulthood 10/5/2012 33 Dr. Rida Akmal DHQ Hospital Fsd

Diagnostic Criteria: Primary Hyperhidrosis:

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 10/5/2012 34 Dr. Rida Akmal DHQ Hospital Fsd

What is Hyperhidrosis?:

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 10/5/2012 35 Dr. Rida Akmal DHQ Hospital Fsd

Cause:

Cause Exact cause is unknown Familial or genetic? Excessive Sympathetic Activity? 10/5/2012 36 Dr. Rida Akmal DHQ Hospital Fsd

Excessive Sympathetic Activity:

Excessive Sympathetic Activity The eccrine sweat glands are excessively stimulated by acetylcholine Increased SWEAT production 10/5/2012 37 Dr. Rida Akmal DHQ Hospital Fsd

Excessive Sympathetic Activity:

Excessive Sympathetic Activity Because the sweat glands are continuously stimulated, they are stuck in the position 10/5/2012 38 Dr. Rida Akmal DHQ Hospital Fsd

QUIZ TIME!:

QUIZ TIME! Those diagnosed with hyperhidrosis have abnormal eccrine sweat glands. TRUE FALSE 10/5/2012 39 Dr. Rida Akmal DHQ Hospital Fsd

GOOD JOB!:

GOOD JOB! The sweat glands are normal, with no variance in size, shape, or number! 10/5/2012 40 Dr. Rida Akmal DHQ Hospital Fsd

SORRY!:

SORRY! Try again…. 10/5/2012 41 Dr. Rida Akmal DHQ Hospital Fsd

Question 2:

Question 2 Hyperhidrosis involves which sweat gland type? Apocrine Eccrine 10/5/2012 42 Dr. Rida Akmal DHQ Hospital Fsd

Oops!:

Oops! 10/5/2012 43 Dr. Rida Akmal DHQ Hospital Fsd

YES!!:

YES!! Hyperhidrosis involves the eccrine sweat glands! 10/5/2012 44 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

10/5/2012 45 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Rules to Follow: Different treatment for areas affected Always start with least invasive treatment option 10/5/2012 46 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 47 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment:

Topical Treatment First line treatment Aluminum Chloride Hexahydrate antiperspirant of choice Most beneficial for axillary hyperhidrosis Can be used for plantar and palmar Photos used with permission: www.feelbest.com 10/5/2012 48 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment: How Does it Work?:

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. 10/5/2012 49 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment:

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 10/5/2012 50 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment: How to Use:

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 10/5/2012 51 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment: Pros and Cons:

Topical Treatment: Pros and Cons Non – invasive Itching and burning of skin at application site & Time-consuming & Temporary relief 10/5/2012 52 Dr. Rida Akmal DHQ Hospital Fsd

Topical Treatment: Effectiveness:

Topical Treatment: Effectiveness 66.6% stop using due to the “CONS” 88% effective for Axillary Hyperhidrosis 10/5/2012 53 Dr. Rida Akmal DHQ Hospital Fsd

QUICK REVIEW!:

QUICK REVIEW! Fill in the Blank! Topical Treatments work by ________ sweat glands. Destroying Plugging Melting 10/5/2012 54 Dr. Rida Akmal DHQ Hospital Fsd

That’s Right!:

That’s Right! Topical Treatments PLUG the sweat gland 10/5/2012 55 Dr. Rida Akmal DHQ Hospital Fsd

Sorry!:

Sorry! HINT: Sweat production never stops, the output is simply blocked! 10/5/2012 56 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 57 Dr. Rida Akmal DHQ Hospital Fsd

Systemic Treatment:

Systemic Treatment Anticholinergics can be used in treating hyperhidrosis Most effective for cranio-facial hyerhidrosis Robinul – drug of choice 10/5/2012 58 Dr. Rida Akmal DHQ Hospital Fsd

How Does it Work?:

How Does it Work? Anticholinergic Blocks Acetylcholine transmission Eccrine sweat glands no longer stimulated Sweat production ceases! 10/5/2012 59 Dr. Rida Akmal DHQ Hospital Fsd

Anticholinergics:

Anticholinergics Long term therapy is required Major side effects: Dry mouth Dry eyes Constipation Blurred vision Difficulty with urination 10/5/2012 60 Dr. Rida Akmal DHQ Hospital Fsd

Anticholinergics:

Anticholinergics Limited use in treating hyperhidrosis Only 21% effective 69.7% stop using due to side effects 10/5/2012 61 Dr. Rida Akmal DHQ Hospital Fsd

Review:

Review Anticholinergics block transmission of ? Catecholamines Epinephrine Acetylcholine 10/5/2012 62 Dr. Rida Akmal DHQ Hospital Fsd

Yes!!:

Yes!! Acetylcholine transmission is blocked! 10/5/2012 63 Dr. Rida Akmal DHQ Hospital Fsd

Sorry!:

Sorry! 10/5/2012 64 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 65 Dr. Rida Akmal DHQ Hospital Fsd

Iontophoresis:

Iontophoresis Used for palmar and plantar hyperhidrosis Passage of direct electrical current onto skin’s surface Device can be purchased for home use 10/5/2012 66 Dr. Rida Akmal DHQ Hospital Fsd

Iontophoresis:

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 Thomas, Brown, & Vafaie, 2004 10/5/2012 67 Dr. Rida Akmal DHQ Hospital Fsd

Iontophoresis: Mechanism of Action:

Iontophoresis: Mechanism of Action WATER + ELECTRICTY = Thickening of skin And Blocked sweat flow 10/5/2012 68 Dr. Rida Akmal DHQ Hospital Fsd

Iontophoresis:

Iontophoresis Side effects: Skin irritation Skin burns Vesicle formation Time consuming treatment 80% effective for palmar and/or plantar hyperidrosis 10/5/2012 69 Dr. Rida Akmal DHQ Hospital Fsd

Iontophoresis:

Iontophoresis Contraindicated in those: Who are pregnant Have pacemakers Have metal implants Have cardiac conditions Have epilepsy 10/5/2012 70 Dr. Rida Akmal DHQ Hospital Fsd

Question….:

Question…. Iontophoresis is NOT used in treating which type of hyperhidrosis? Palmar Axillary Plantar 10/5/2012 71 Dr. Rida Akmal DHQ Hospital Fsd

Yes!:

Yes! Iontophoresis can be used in treating Palmar and/or Plantar hyperhidrosis 10/5/2012 72 Dr. Rida Akmal DHQ Hospital Fsd

PowerPoint Presentation:

HINT: Look at these pictures…. Try Again! 10/5/2012 73 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 74 Dr. Rida Akmal DHQ Hospital Fsd

Botox:

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 10/5/2012 75 Dr. Rida Akmal DHQ Hospital Fsd

Botox:

Botox Starch Iodine test done prior to injection Delineates areas of excess sweating with black-purple discoloration of the skin 10/5/2012 76 Dr. Rida Akmal DHQ Hospital Fsd

Botox:

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 10/5/2012 77 Dr. Rida Akmal DHQ Hospital Fsd

Botox:

Botox Cons: Very painful to the palms and soles of feet Pros: Lasts 6-7 months 90% effective 10/5/2012 78 Dr. Rida Akmal DHQ Hospital Fsd

Quick Review:

Quick Review A Starch-Iodine test is done prior to botox injection. True False 10/5/2012 79 Dr. Rida Akmal DHQ Hospital Fsd

Correct!:

Correct! This test highlights areas of excessive sweating! 10/5/2012 80 Dr. Rida Akmal DHQ Hospital Fsd

Try Again!:

Try Again! Hint: The test gives a “map,” highlighting areas of excessive sweating 10/5/2012 81 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 82 Dr. Rida Akmal DHQ Hospital Fsd

Local Excision:

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 10/5/2012 83 Dr. Rida Akmal DHQ Hospital Fsd

Local Excision:

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 10/5/2012 84 Dr. Rida Akmal DHQ Hospital Fsd

Local Excision:

Local Excision Starch Iodine tests done post excision show 80% - 90% decrease in sweating Has a potential for scarring 10/5/2012 85 Dr. Rida Akmal DHQ Hospital Fsd

Review!:

Review! Local Excision is used for what type of hyperhidrosis? Plantar Palmar Axillary 10/5/2012 86 Dr. Rida Akmal DHQ Hospital Fsd

Correct!:

Correct! Local Excision is used for axillary hyperhidrosis! 10/5/2012 87 Dr. Rida Akmal DHQ Hospital Fsd

Try Again!:

Try Again! 10/5/2012 88 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Options:

Treatment Options Topical Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy 10/5/2012 89 Dr. Rida Akmal DHQ Hospital Fsd

Endoscopic Thoracic Sympathectomy (ETS):

Endoscopic Thoracic Sympathectomy (ETS) Last treatment option PERMANENT Surgery performed under general anesthesia 10/5/2012 90 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

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 10/5/2012 91 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

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 10/5/2012 92 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

ETS Ganglion located along the sympathetic chain Ganglion formed below each rib Ganglion can be divided = sympathicotomy Ganglion can be removed = sympathectomy 10/5/2012 93 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

ETS Ganglion at T2 and T3 = palmar hyperhidrosis Ganglion at T3 and T4 = axillary hyperhidrosis Ganglion at L2-L4 = plantar hyperhidrosis 10/5/2012 94 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

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 10/5/2012 95 Dr. Rida Akmal DHQ Hospital Fsd

ETS:

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! 10/5/2012 96 Dr. Rida Akmal DHQ Hospital Fsd

ETS: Side Effects:

ETS: Side Effects Surgical complications: Hemo-pneumothorax requiring chest tube placement – 1% Atelectasis Intercostal neuralgia – 1% Horner’s Syndrome – 1% Compensatory Sweating – 60% 10/5/2012 97 Dr. Rida Akmal DHQ Hospital Fsd

Horner’s Syndrome:

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 10/5/2012 98 Dr. Rida Akmal DHQ Hospital Fsd

Horner’s Syndrome:

Horner’s Syndrome Signs and Symptoms Unilateral upper eyelid ptosis Pupil constriction Facial anhidrosis 10/5/2012 99 Dr. Rida Akmal DHQ Hospital Fsd

Compensatory Sweating:

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 10/5/2012 100 Dr. Rida Akmal DHQ Hospital Fsd

Compensatory Sweating:

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 10/5/2012 101 Dr. Rida Akmal DHQ Hospital Fsd

Compensatory Sweating:

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 10/5/2012 102 Dr. Rida Akmal DHQ Hospital Fsd

Let’s Review:

Let’s Review ETS is performed most often for what type of hyperhidrosis: Axillary Palmar Plantar 10/5/2012 103 Dr. Rida Akmal DHQ Hospital Fsd

CORRECT!:

CORRECT! ETS is performed for palmar hyperhidrosis! 10/5/2012 104 Dr. Rida Akmal DHQ Hospital Fsd

TRY AGAIN!:

TRY AGAIN! 10/5/2012 105 Dr. Rida Akmal DHQ Hospital Fsd

Question 2:

Question 2 What is the most significant side effect of ETS? Hemo-pneumothorax Horner’s Syndrome Compensatory Sweating 10/5/2012 106 Dr. Rida Akmal DHQ Hospital Fsd

That’s Right!:

That’s Right! Compensatory Sweating can occur in 60% of post-op patients! 10/5/2012 107 Dr. Rida Akmal DHQ Hospital Fsd

Sorry!:

Sorry! Horner’s Syndrome and Hemo-pneumothorax only occur in 1% of the cases! 10/5/2012 108 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Option Review:

Treatment Option Review Hyperhidrosis Topical Treatment Botox Iontophoresis Local Excision Iontophoresis Botox ETS AXILLARY PALMOPLANTAR Hornberger, 2004 10/5/2012 109 Dr. Rida Akmal DHQ Hospital Fsd

Treatment Option Review:

Treatment Option Review Systemic – blocks acetylcholine 10/5/2012 110 Dr. Rida Akmal DHQ Hospital Fsd

CONGRATUALTIONS!!:

CONGRATUALTIONS!! 10/5/2012 111 Dr. Rida Akmal DHQ Hospital Fsd

Thank You :

Thank You 10/5/2012 112 Dr. Rida Akmal DHQ Hospital Fsd Dr. Rida Akmal DHQ Hospital Fsd

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