Many Options Available to Treat, Even Cure Hyperhidrosis
Mario Gasparri, MDMedical College of Wisconsin Cardiothoracic Surgeon
Millions of people suffer with excessive sweating, a condition known as hyperhidrosis. It interferes with their daily lives, often causes embarrassment, and can lead to a reduced quality of life. Mario Gasparri, MD, explains that people don’t need to suffer with hyperhidrosis because many treatment options, even cures, are available.
Q. What is hyperhidrosis?In general, hyperhidrosis means excessive sweating — sweating far in excess of the needs of the body — and it’s basically continuously produced with no apparent cause. You can break hyperhidrosis into two types: primary hyperhidrosis and secondary hyperhidrosis. Primary is what I deal with. Secondary means that it’s excessive sweating because of some underlying medical problem. Through a good history and physical, you can exclude all other causes and know what you’re dealing with. With primary hyperhidrosis, there is no underlying medical reason and no apparent cause for this excessive sweating.
There are millions of sweat glands on your body and they’re located in highest concentration in a couple of places — your hands, your feet, your underarms and your face. Two-thirds of the people with hyperhidrosis will be affected on their hands and feet. Maybe another 20 percent will be affected on their hands, feet and underarms, and the rest will be either affected on their underarms only or on their head and face. Those are the most common combinations.
Q. How is hyperhidrosis diagnosed?The criteria to be diagnosed with primary hyperhidrosis, as defined by a consensus panel on hyperhidrosis, include focal, excessive sweating of at least six months duration without apparent cause with at least two of the following characteristics: it’s symmetric or equal on both sides; it impairs daily activities; the age of onset is less than 25 years; and there’s a frequency of at least one episode per week, and there is a family history. So, if you have excessive sweating with two of these criteria, you fall into what we consider primary hyperhidrosis.
Q. What causes hyperhidrosis?We don’t know the cause of this problem. We think it’s hyperfunctioning of the central sweat center, but we don’t why. We know there is a hereditary component because when you take a family history, at least half of the people having surgery to correct it have a family history — for example a sibling, a parent or a grandparent also has it. Other than that we don’t know any other risk factor.
Q. Whom does it affect?There’s an equal distribution between males and females. It’s estimated to affect about 2.8 percent of the population, which translates to almost 8 million people in the United States. It’s not a small population.
The interesting thing is that of those 8 million people, only a third have actually discussed it with their doctors. People don’t bring it up, mainly because they’re embarrassed about it or have been told in the past, “you’re just anxious, don’t worry about it.” They’re really reluctant and become reclusive about it.
Q. At what age do most people notice symptoms? The onset is usually at adolescence. Although it can actually be present from birth, it tends to worsen during adolescence. Most people notice it before age 25. You don’t develop it at age 40 or 50. This is something that’s pretty much there from adolescence on. Sometimes, the mom will tell me, “she’s been sweating since she was a baby.”
Q. What are the signs and symptoms? Basically, it’s excessive sweating. I had one patient tell me, go wash your hands and don’t dry them at all so your hands are sopping wet, and then try to do all your normal activities. That’s what it’s like. People with hyperhidrosis can’t perform normal daily tasks. They have difficult writing on paper and they have difficulty driving. I had one patient who was scared to hold her baby for fear of dropping her. They have problems working, they can’t hold certain instruments and there are certain careers they just can’t do.
Hyperhidrosis also causes actual physical discomfort because the continuously wet shoes and clothing can lead to skin breakdown and fungal infections. It causes social issues when they have completely sopping wet underarms. They have to change multiple shirts a day, they won’t shake hands or hold hands because it’s so embarrassing. Overall, if you put all of this together, it leads to a diminished quality of life.
The quality of life surveys from people with hyperhidrosis are comparable to people with end-stage kidney disease on dialysis or rheumatoid arthritis or multiple sclerosis. For the individual with hyperhidrosis, it can be pretty devastating.
Hyperhidrosis can be both cured and/or controlled. You can just control the symptoms, make the sweating tolerable and keep yourself as dry as possible. Or, you can go for an actual cure so the sweating is eliminated.
Q. Can it be cured?
If you look at the whole sweating cascade, your brain gets the impulse to sweat, sends it down something called the sympathetic chain, which is the main nerve that sends the signal to the sweat glands. Then the sweat glands get activated and they sweat. You can attack this problem anywhere along that chain.
Q. What treatment options are out there?There are several options ranging from non-invasive to surgical. There are prescription antiperspirants, medicines, Botox injections and other options.
The simplest is to do something at the skin level. You can use a super, super strong antiperspirant called Drysol. It’s an aluminum chloride based product and the aluminum salts crystallize and plug the sweat glands. As the skin is shed and new skin forms, your sweating comes back.
There’s something else you can do at the skin level called iontophoresis. This involves passing an electrical current through the skin. It’s almost like a little water bath, just a shallow pan of water. You put your hands in there or your feet in there, and as the electrical current goes through the water, it interferes somehow with your sweat glands so that you stay dry.
Then you can move up to the next invasive option. There are some medicines you can take called anticholinergics. The most commonly used one in this category is called Robinul. This is a medicine that interferes with the chemical that goes between the nerve and sweat gland. But it’s non-specific — it blocks that chemical everywhere in the body.
The next invasive option is Botox or botulinum toxin. Botox is basically a poison produced by the bacteria, clostridium botulinum. It blocks nerve transmission at the nerve/sweat gland junction. It paralyzes that nerve.
For underarm hyperhidrosis, there’s something that our plastic surgeons are doing here now called arthroscopic axillary gland excision (or removal). David Larson. MD, FACS, chair of our plastic surgery department, has done these. He’s been very happy with this technique. It’s basically a cure.
The surgical option, which is what I do, is called thoracascopic sympathectomy — also called endoscopic thoracic sympathectomy or ETS. What we do with this operation is just interrupt the sympathetic chain.
This chain is long. It starts in your neck and goes all the way down to your belly along the back of your chest wall. We know that there are certain ganglia — certain portions of the chain — that control certain parts of your body. For example the T2 and T3, the part that’s located between or below the second and third rib, controls your hand. The part that lives below your fourth and fifth rib controls your underarm.
We make two small, dime-sized incisions. We make the incision in the underarm and we put a little camera scope in there. In the other incision, I put some instruments and we find the 2-3 level, which we know controls the hand, and we take that portion of the chain out. We just remove it. The surgery itself takes about one to two hours. Most people stay overnight, and they’re back to normal within one to two weeks. It’s a pretty quick recovery.
Q. How effective is the ETS surgery?For palms, after this operation, basically you’re cured. There’s a 95 percent or higher success and satisfaction rate. They are dry by the time they leave the operating room. It’s immediate.
For the feet, even though we’re not quite sure why, about two-thirds of patients will respond and their feet will get dry as well. For the underarms, it’s only about a 50 percent to 60 percent proposition. I don’t use this operation for primary underarm sweating because there’s the arthroscopic axillary gland excision that Dr. Larson does. It’s basically a cure.
For facial hyperhidrosis, it’s also about a 50/50 proposition, so I don’t use this for those patients because the drug Robinul tends to work. Of all the people we’ve operated on at this institution, we’ve done only one craniofacial hyperhidrosis. I don’t advocate this operation, at least up front, for that condition.
Q. Are there any adverse affects of the ETS surgery? There are certainly possible complications, some that are generic to any operation you do, such as bleeding or infection. At Froedtert & the Medical College of Wisconsin, it should be less than 1 percent. There’s also a complication called Horner’s syndrome. That happens if you injure a part of the chain that’s above where we work called the Stellate ganglion. It can cause problems such as droopy eyelids and constricted pupils. The droopy eyelid is really what’s most distressing to the patient. It’s the most dreaded complication, but fortunately it’s quite rare. We’ve never had one at this institution. In the literature, it can happen as much as 1 percent of the time, but it’s very rare.
Probably the most common complication is something called compensatory hyperhidrosis, which means that instead of sweating on their hands or underarms, they sweat elsewhere. It’s usually along their trunk, in the back and buttocks area. If you look for it, that will happen as high as 75 or 80 percent of the time. But, if you ask these people, it’s very well tolerated. It’s much less sweating and 99 percent of the people who get it are much happier with this sweating than what they started with. Only 1 percent of the time are the people unhappy with this compensatory hyperhidrosis. It can’t be treated surgically, but that’s one area again where Robinul has had some success. Of our last forty patients, we had one person who had compensatory hyperhidrosis that was bad enough to be started on a very low dose of Robinul. It’s a common complication, but only rarely is it a problem.
Q. How effective are the other treatment options?When using Drysol, you have to be perfectly dry first, which can be difficult. You apply this antiperspirant and it has to stay on for six to eight hours. Most people do it at night and wash it off in the morning. You do this daily until you get to the point where you’re dry. If it works, you may get to the point where you apply it once a week. It can be messy and maybe two-thirds of people will get some sort of satisfactory control with weekly applications. It’s not cured, but the sweating is cut down to the point where it’s livable.
With palms, it’s less effective and often you need higher concentrations of these powerful antiperspirants. There are side effects, too. It can cause a lot of itching or stinging and skin irritations, where it actually becomes quite painful to apply. Although it works in some people, it’s something you’d have to do for the rest of your life.
With iontophoresis, usually you start at a very low current and increase the current until it starts tingling. Most people do it three to four times a week for 20 to 30 minutes per session. If you’re going to see a response, it usually happens after six to 10 treatments. Then you get it down to a session every one to three weeks. The success is mixed — it’s about a 50/50 proposition.
Medications like Robinul will dry you up and inactivate your sweat glands chemically. It will also inactivate everything else in your body that relies on this chemical for stimulation. You have to try low doses and just start increasing the dose until people are dry. The problem is the side effects. You get dry eyes, dry mouth, blurred vision and urinary retention because it’s affecting your whole body.
The subset of hyperhidrosis where Robinul has shown some success is for people who have what we call craniofacial or facial hyperhidrosis. For those patients, for whatever reason, it’s controlled with much lower doses of Robinul so that it works for them. But for palms or feet or underarms, the side effects are too much.
For Botox treatments, there are different techniques. In general, for hand hyperhidrosis for example, you’ve got to anesthetize the hand. You might do something called a wrist block where you inject local anesthesia at the wrist so the whole hand is numb, or you might block it all the way up at the underarm. Some people actually have to go to sleep for this because it’s somewhat painful.
Using Botox, you can do anywhere from 20 to 50 injections in various areas of the whole palm and finger pads. It’s a bunch of little injections with a tiny little needle all over your palm. Botox can be very successful for palms and underarms. Initially, 90 percent of the people will be dry. The problem is that it’s temporary. For the palms, even in the best series, I’ve seen average lengths of response of about five months. For the underarm, it may be as high as eight months. After that time period, the sweating comes back so patients have to get repeated injections over the course of their life.
The problem with this technique, other than it comes back, is it hurts. To get 20 to 50 injections in the palm of your hand can be pretty painful. As a side effect on your hands, it can cause a lot of weakness, because it’s interfering with some nerve transmission. Some people, at least for a week or two afterwards, have problems with finger pinching or grip strength. But it’s another option. Botox does work and some people are very happy going back every six or eight months and getting repeat injections.
For the plastic surgery procedure, they map out the target area in your underarm, and they make a tiny incision, a dime size or smaller. They use a small arthroscopic shaver — it’s about the size of a pencil — and they put it through this hole and pass it back and forth to destroy or remove all the sweat glands in that area right under the skin.
The whole procedure takes about 45 minutes and people are back to work in three or four days. In the information Dr. Larson showed me, patients have had a 75 percent decrease in sweating severity. Ninety-six percent of the people were satisfied. There’s really no significant complications from this — it’s a skin procedure.
Q. How does a patient know which option is right for him or her?There are many treatment options available and each one has its own specific risk/benefit ratio. Which treatment we use really depends on how severe the symptoms are, how compliant or able they are to tolerate whatever therapy they’ve chosen, and where they are affected.
I’ll counsel them on every method available and then we typically will start with the least invasive or easiest treatment and move on to the most invasive. If someone comes to see me with a combination of feet, hands and underarms, I’ll start with the medical options and ask if they’ve used Drysol. If they haven’t, we’ll start them on that. If they have — and I can tell you most people have already used it — they’ll tell me it’s not controlling their symptoms, or it hurts when then put it on or it's just too messy and they can’t do it.
Then, I talk to them about iontophoresis, and most people really just aren’t interested in putting the current through their hands. If they’re interested, we’ll try that first. Then we’ll talk to them about Botox. Again, sometimes some people will try it. Every one of my patients who has tried it has come back because it failed within a month or two.
Some people will say “I don’t want Botox. I’m scared to get 50 injections in my hand.” But I’ll offer that as the next step. If they either refuse to have these therapies or have failed these therapies, then we talk about sympathectomy, the surgery.
If they come to me and their only component is the underarm, I would start with the Drysol and so forth. I would also send them to the plastic surgeons, to Dr. Larsen to counsel them on axillary gland excision.
And finally, for craniofacial, if that’s their main symptom, I start them on Robinul. We’ve had pretty good success medically managing this. I’ve only had to operate on one person with craniofacial hyperhidrosis, but that’s because they basically failed Robinul and were miserable. They did fine and had no more blushing and sweating. Even though the numbers out there say the success rate for surgery to treat craniofacial hyperhidrosis can be as high as 50 percent, I’m not convinced. I don’t encourage surgery for people with craniofacial hyperhidrosis.
Q. How many years do most people live with it before they see a doctor?It’s many. The bulk of the people I operate on are in their mid 20s and 30s, and almost every one of them comes in with a story about how they went to their pediatrician in their early teens and were told “don’t worry, you’ll outgrow it” or “you’re just being anxious.” So they just live with it. Then they become a little more educated. Especially now with so much information out there on the Internet, they start looking around. Probably 90 percent of the patients who come to see me are self-referred because they’ve read about hyperhidrosis on the Internet and now understand that there are surgical options. Very few of them are actually referred by their primary care physicians. I think everyone needs to be better educated on this, not only patients, but the whole medical community.
Q. Why do people need to know about hyperhidrosis?People and physicians need to know what’s out there to treat this. It’s kind of disturbing how little people know about this. I think we just need some education on this because there are a lot of people out there who have this problem.
The consensus panel that defined hyperhidrosis — one of their recommendations is that physicians or primary care doctors should always ask about a patient’s sweating history because it’s potentially such a common thing and people are so reluctant to talk about it. When you’re going through a review of symptoms or doing a history, and asking about a history of headaches, fevers chills, etc., doctors should ask about sweating. It should just be something that becomes routine.
Source: Every Day, Interview with Mario Gasparri, MD
Date: Aug - Dec 2006