Transcript HYPERHIDROSIS: Treatment Approaches

HYPERHIDROSIS:
A Comprehensive Review
Dina Hamadi, R.N., B.S.N.
Alverno College:
Master’s of Science in Nursing
Navigating the Tutorial
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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
What makes me sweat?
What is Hyperhidrosis?
Treatment Options
Sweat Glands
The human body has 2-5 million sweat
glands
Two main types:
ECCRINE
Click on the different sweat
gland types to learn more!
Source: www.sweathelp.org
Click the “Home” button after viewing both types
APOCRINE
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
CLICK HERE
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
CLICK HERE
Sweating
The hypothalamus serves as the
thermoregulatory center
It controls both blood flow and sweat
output to the skin’s surface
Source: www.sweathelp.org
Sweating
The hypothalamus can be triggered by:
EXERCISE
STRESS
TEMPERATURE CHANGE
HORMONES
Source: www.sweathelp.org
Sweating
Once triggered,
the hypothalamus sends messages down the
spinal cord
via neurotransmitters.
Source: www.sweathelp.org
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
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-T4 innervate
the skin of the face
T4-T12 innervate the
skin of the trunk
Source: www.sweathelp.org
T2 – T8 innervate the
skin of the upper limbs
T10-T12 innervate the skin
of the lower limbs
Neurotransmitters
Acetylcholine
innervates
Eccrine Sweat
Glands
Source: www.sweathelp.org
Catecholamines
innervate
Apocrine Sweat
Glands
Sweating
Once innervated, the apocrine and eccrine
glands will produce ….
Source: www.sweathelp.org
SWEAT!
Click on the picture to take the “Sweating Quiz”
Click on the “Home” button to return to the topic choices
Question 1
What serves as the body’s thermoregulatory
center?
a.
b.
c.
The hypothalamus
The adrenal cortex
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?
a. The hypothalamus
b. The adrenal cortex
c. The frontal lobe
Question 2
What neurotransmitter innervates eccrine
sweat glands?
a.
b.
c.
Acetylcholine
Catecholamine
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
b. Exercise
c. Obesity
d. Temperature change
CORRECT!!
You have successfully completed this section of the tutorial. Return home!
Try Again!
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,
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?
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!
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
Topical
Treatment Options
Click on the first treatment
option to begin!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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
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
Topical Treatment
Sweat production never
ceases, the gland is simply
plugged
Sweating will return as the
skin undergoes
regeneration or shedding
Photo used with permission:
Neurosurgical Medical Clinic, Inc
Therefore…topical
treatment is NOT a cure!
Hornberger, 2004
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 13 weeks
Hornberger, 2004
Topical Treatment:
Pros and Cons
Hornberger, 2004
Topical Treatment:
Effectiveness
88% effective for
Axillary Hyperhidrosis
66.6% stop using due
to the “CONS”
Naumann, Hamm, & Lowe, 2002
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!
Topical
Treatment Options
Click on the second treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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 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.
b.
c.
Catecholamines
Epinephrine
Acetylcholine
Yes!!
Acetylcholine transmission is blocked!
Take me to the next treatment option!
Sorry!
Click on the picture to try again!
Topical
Treatment Options
Click on the third treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Iontophoresis
 Used
for palmar and
plantar hyperhidrosis
 Passage
of direct
electrical current onto
skin’s surface
 Device
can be purchased
for home use
Thomas, Brown, & Vafaie, 200 4
Photo used with permission: Beast Psoriasis, 2006
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
Iontophoresis:
Mechanism of Action
+
WATER
www.sweathelp.org
=
ELECTRICTY
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
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.
b.
c.
Palmar
Axillary
Plantar
Yes!
Iontophoresis can be
used in treating
Palmar and/or Plantar
hyperhidrosis
Take me to the next treatment option
Try Again!
HINT: Look at these pictures….
Click on either picture to
Try again!
Photos used with permission: Beat Psoriasis, 2006
Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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
Haider & Solish, 2004
Photo used with permission:
Eisenach, Atkinson, & Fealey, 2005
Botox
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
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
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!
Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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
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
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.
b.
c.
Plantar
Palmar
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!
Topical
Treatment Options
Click on the fourth treatment
option!
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
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
Han, Oren, & Gottfried, 2002
Photo used with permission:
Neurosurgical Medical Clinic, Inc
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
www.sweathelp.org
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
www.sweathelp.org
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
www.sweathelp.org
Horner’s Syndrome
Signs and Symptoms
Unilateral upper eyelid ptosis
Pupil constriction
Facial anhidrosis
www.sweathelp.org
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
www.sweathelp.org
Photo used with permission:
ETS Discussion Forum and Reversals, 2005
Compensatory Sweating
Mechanism poorly understood
Theory states:
Photo used with permission:
ETS Discussion Forum and Reversals, 200
After excision of T2 and T3, 40% of
body’s sweat function is lost
Body tries to compensate for this loss
Andrews & Rennie, 1997
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.
b.
c.
Axillary
Palmar
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.
b.
c.
Hemo-pneumothorax
Horner’s Syndrome
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 Hemopneumothorax only occur in 1% of the
cases!
Click on the face to try again!
Treatment Option Review
AXILLARY
Hyperhidrosis
PALMOPLANTAR
Topical Treatment
Botox
Iontophoresis
Local Excision
Iontophoresis
Botox
ETS
Hornberger, 2004
Treatment Option Review
Systemic – blocks
acetylcholine
Photo used with permission: The Whiteley Clinic, 2007
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), 1702-1704.
Beat Psoriasis. (2006). What is hyperhidrosis or excessive sweating? Retrieved
March 22, 2007, from www.beatpsoriasis.com.
Canada’s Largest Online Health and Beauty Aids. (n.d.). Retrieved April 12,
2007, from www.feelbest.com.
Eisenach, J., Atkinson, J., & Fealey, R. (2005). Hyperhidrosis: Evolving
therapies for a well-established phenomenon. Mayo Clinic Proceedings,
80(5), 657-666.
ETS Discussion Forum and Reversals. (2005). Compensatory sweating after
ets. Retrieved March 22, 2007, from
http://p069.ezboard.com/fetsandreversalsfrm37.showMessage?topicI
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, 1075-1079.
Haider, A. & Solish, N. (2004). Hyperhidrosis: An approach to diagnosis and
management. Dermatology Nursing, 16(6), 515-523.
References
Hamm, H., Naumann, M., & Kowalski, J. (2006). Primary focal hyperhidrosis: Disease
characteristics and functional impairment. Dermatology, 212. 343-353.
Hornberger, J. (2004). Recognition, diagnosis, and treatment of primary focal
hyperhidrosis. Journal of the American Academy of Dermatology, 51(2), 274-286.
International Hyperhidrosis Society. (2007). About hyperhidrosis: Physiology of normal
sweating. Retrieved March 7, 2007, from http://www.sweathelp.org.
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, 1218-1226.
Neurosurgical Medical Clinic, Inc. (n.d.). Neurosurgical Diseases: Hyperhidrosis.
Retrieved March 23, 2007, from www.sdneurosurgeon.com/diseases/hyperhidrosis.html.
Thomas, I., Brown, J. & Vafaie, J. (2004). Palmoplantar hyperhidrosis: A therapeutic
challenge. American Family Physician, 69(5,) 1117-1120.
Unatrributed Clip Art: Microsoft Office, 2006.
University of Miami Cosmetic Center. (2007). Botox for Hyperhidrosis. Retrieved April 10,
2007, from www.derm.net/bo_hyperhidrosis.shtml.
Whiteley Clinic. (2007). The latest treatment in excessive sweating. Retrieved April 2,
2007, from www.sweating.co.uk.