Transcript SKIN DEEP A Clinical Case of Primary Hyperhidrosis

SKIN DEEP
A Clinical Case of
Primary Hyperhidrosis
Usaima Siddiqi Ahmad, PDTF, OMS IV
Date of Patient Exam: Sep. 1, 2008
Student Year at That Time: OMS III
Supervising Physician: Rebecca Giusti, D.O.
COMP, Western University of Health Sciences
Case
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CC: “sweaty hands, armpits, and feet”
HPI
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A 23 y/o female presents with excessive palmar,
axillary, and plantar perspiration that began at age
eleven, near the time of menarche.
She states that warm to hot temperatures, stress
(emotional or physical), and anxiety exacerbate her
condition, while colder temperatures and a full night
of sleep are palliative.
Once started, symptoms tend to persist throughout
the entire day without relief.
HPI Continued
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She has tried prescription strength deodorants,
topical solutions, and iontophoresis without relief.
She has a prescription for anti-cholinergics, but has
not tried them due to feared side effects.
Pt. states she is currently a 6/10 on a “Perspiration”
scale that we developed together
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Perspiration Scale
• 0 = asymptomatic
• 5 = “clamminess” in affected areas
• 10= “dripping” sweat from affected areas
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No associated symptoms noted, per patient
PMH, SxH, Rxs, Allergies, FH
PMH: unremarkable; no falls, trauma, motor
vehicle accidents
 SxH: unremarkable
 Medications: none
 Allergies: NKDA, no environmental allergies
 FH: Healthy parents. Brother has palmar
hyperhidrosis (much less severe, per pt).
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Social History
OMS-I
 Single, not sexually active
 No tobacco use, marijuana use, or other
illicit drug use
 Occasional/social alcohol use
 Caffeine: One 12 oz. cup per day
 Psychosocial Stressors
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Boundaries
• Personal relationships: hand holding
• Professional life: hand shaking, stains on clothing
Physical
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VS, HEENT, CV, Resp, and Abd Exam
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Extremities
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Deferred
Pulses intact bilaterally in UE and LE
No clubbing, cyanosis, nor edema noted
Neurological
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Gait: N
CN II- XII grossly intact
Sensation: Grossly intact over UE and LE B/L and
trunk
DTRs: +2/4 patellar and biceps, bilaterally
Structural Exam, At Initial Visit
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Head (H)
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Increased venous congestion, SBS
compression, restricted right OM suture
Cervical Region (C)
OA: FRLSR, C3-6 FRRSR
 TART changes noted throughout region
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Thoracic Region (T)
Restricted Supraclavicular fossa, B/L
 T2-3 NRLSR, T7-9 ERRSR
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Initial Structural Exam, Cont
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Ribs (R)
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Right Rib 1: Inh SD, Left Rib 5: Inh SD
Lumbar Region (L)
L1-2 FRLSL, L5ERLSL
 Hypertonicity in paravertebral mm. B/L
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Sacral Region (S)
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R/L sacral torsion
Upper Extremities (UE)
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Tenderness during passive ROM of right
glenohumeral joint
Assessment
1. SD of the H,C, T, R, L, S, UE
 2. Primary Focal Hyperhidrosis
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Isolated to the following areas:
• Axillary
• Palmar
• Plantar
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As opposed to Secondary or Generalized
Hyperhidrosis
Hyperhidrosis
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Unknown Etiology
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? Genetic component
• FH is a component in ¼ of patients
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Primary vs. Secondary
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Adolescence vs. Any time in life
Craniofacial, axillary, palmar, plantar, full body
0.6-1.0% of population is effected
“Occasional” spontaneous regression after age 35
Palmar or plantar keratoderma may occur
Treatment Options and Side Effects
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Home Remedies- cornstarch
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Low efficacy for most
patients
Tx Reaction, rarely
permanent
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Only effective for axillary
type
 Skin irritation, low efficacy in
moderate-severe cases
Topical Agents (aluminum based)
 Skin irritation, low efficacy in
moderate-severe cases
 Theoretically oncogenic
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Expense, time consumingdaily, and may cause
dermatitis
Botulinum Toxin (BTX-A)
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Blurry vision, dry mouth, dry
membranes, urinary
retention, constipation,
anorexia
Iontophoresis
Deodorants (OTC and
Prescription)
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Anticholinergics
OMM
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Expense, painful, results last
about 4 months
Repetitive injections
Endoscopic Transthoracic
Sympathectomy (ETS) and Lumbar
Sympathectomy
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Surgical procedure, Horner’s
Syndrome, compensatory
hyperhidrosis
Osteopathic Approach
to Patient Care
Neurological
Circulatory/
Respiratory
Biomechanical
Biopsychosocial
Metabolic
Biomechanical
Biomechanical
Neurological
Circulatory/
Respiratory
Biopsychosocial
Metabolic
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Address Somatic Dysfunction
Recurrent findings on patient
 OA and T2-3 somatic dysfunctions, sacral
torsion
Regions Addressed
Head:
SBS
Decompression
Venous Sinus
Drainage
HVLA to OA
Suboccipital
Release
Cervicals:
BLT, ST, MFR
Thoracics and
Lumbars:
HVLA, ME, ST,
MFR
Ribs:
BLT, HVLA
Pelvis and Sacrum:
ME, CrS
Neurofascial Release
Also performed during Tx 3-4
Neurological
Ne urological
Biome chanical
Circulatory/
Re spiratory
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Biopsychosocial
M e tabolic
Balancing the Autonomic Nervous System
 OMT to cervical and sacral areas for
parasympathetic balance
 OMT to thoracic, lumbar, and costal regions for
sympathetic balance
Autonomic Control
Sympathetic:
Parasympathetic:
Vagus Nerve:
exits cranium
near OA
Sympathetic
Chain
T1-L2
Sacral Plexus
S2-S4
Circulatory/Respiratory
and Metabolic
Ne urological
Biome chanical
Circulatory/
Re spiratory
Biopsychosocial
M e tabolic
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“…Localized segmental insults to the musculoskeletal
system… produced rather substantial disturbances in the
sympathetic function, at least as reflected in sweat-gland
activity and in vascular and circulatory changes.” –I.M. Korr
OMT to transition zones improved C/R functions
1
Relieving somatic dysfunction leads to:
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Decreased energy demand
Decreased energy expenditure
1Buzzell,
1970
Biopsychosocial
Neurological
Biomechanical
Circulatory/
Respiratory
Biopsychosocial
M etabolic
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Online Support Groups
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www.thedailystrength.org, www.hyperhidrosis.org, facebook.com
Classmates
Decreased severity of condition with treatments
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Increased social contact
Decreased anxiety in social situations
Outcomes
Pre and Post Tx Outcomes per Week
10
Pre-Tx
Post-Tx
Days of Relief
9
7
Days of Relief
Perspiration Scale Value
8
6
5
4
3
2
1
0
1
2
3
Visit (Week)
4
*Data Obtained
Sep 2008
Conclusion
Students can make a difference
 This case illustrates that OMM can
influence autonomic function
 Structure influences function at many
different levels
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References
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Buzzell, Keith A. “The Cost of Human Posture.” The Physiological Basis of
Osteopathic Medicine. Pg63-72. New York: Post Graduate Institute of Osteopathic
Medicine and Surgery,1970. Pg63-72.
Kuchera, William A., and Michael L. Kuchera.”Research and the Osteopathic
Concept.” Osteopathic Principles in Practice. 2nd ed. Kirksville, Mo.: Kirksville
College of Osteopathic Medicine, 1991. Print. Kuchera and Kuchera.
Korr, Irvin M. The Collected Papers of Irvin M. Korr. Ed. Barbara Peterson.
Colorado Springs: American Academy of Osteopathy, 1979. Print.
Korr, Irvin M. "The Segmental Nervous System as a Mediator and Organizer of
Disease Processes." The Physiological Basis of Osteopathic Medicine. New York:
Postgraduate Institute of Osteopathic Medicine and Surgery, 1970. Print. Pg 73-84.
Fealey Robert D, Sato Kenzo, "Chapter 82. Disorders of the Eccrine Sweat Glands
and Sweating.” Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ:
Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2985825.
Low Phillip A, Engstrom John W, "Chapter 370. Disorders of the Autonomic
Nervous System." Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL,
Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e:
www.accessmedicine.com/content.aspx?aID=2906166.
http://www.accessmedicine.com/content.aspx?aID=2906166.
Ropper AH, Samuels MA, "Chapter 26. Disorders of the Autonomic Nervous
System, Respiration, and Swallowing.” Ropper AH, Samuels MA: Adams and
Victor's Principles of Neurology, 9e: http://www.accessmedicine.com/