Hyperhidrosis is a condition in which there is excessive sweating either in the hands or the feet or in the head and neck. It may occasionally be associated with facial blushing. This condition can be socially isolating and embarrassing. A patient’s experience of various areas of increased sweating with an inference of activities of normal daily living. They may sweat profusely from their hands even to the point where writing using a pen can cause the paper to become waterlogged with ink being smudged across the paper. It can also be socially embarrassing during greetings. Patients with axillary hyperhidrosis are equally socially concerned about their presentation when greeting people. Hyperhidrosis of the feet is another problem in patients particularly involving sporting activities and some patients may find that they go through socks and shoes very rapidly as the sweating causes deterioration in those articles.
Most patients who present to discuss their hyperhidrosis have already been through some of the pharmalogical agents that can assist them. These include antiperspirants and anticholinergic agents such as dry claw.
The options for treatment include:
Iontophoresis – this involves the use of a current that is put through a water bath environment to switch off the sweat glands and thus can be repeated but usually last approximately three to four months after each treatment.
Botox Injections – Botox injections can be given into the hands and also the axillary to switch off the sweat glands. Once again this is a treatment that needs to be repeated three times a year and is expensive, but nevertheless, particularly in the axillary it can be very effective. The side effects in the hands are weakening occasionally of some of the muscles and so it may interfere with hand function and so its best avoided.
Endoscopic thoracic sympathectomy – during this procedure the sympathetic nerves that control sweating from the level of the nipple line upwards are divided and excised using a thoracoscopic approach. This involves a general anaesthetic with the lung being deflated on the operated side and the sympathetic nerves interrupted usually using diathermy and a segment excised or cauterised. This treatment is more reliable with a palmar hyperhidrosis and less so with axillary hyperhidrosis although there is about a 70 to 80% rate of effectiveness in the axillary region.
Possible complications with this technique include
- Injury to intrathoracic structures. This may cause pneumothorax, hemothorax.
- Brachial neuralgia. The patient may feel an aching along the arm which occurs within the 24-48 hours after the procedure and this will settle.
- Horner’s Syndrome. This can occasionally occur if there is an injury to the upper part of the sympathetic chain. This area is usually avoided. The condition presents as one of drooping of the eyelid and small pupil. The eyelid droop can be fixed by an eyelid lift but the pupil changes would remain permanent.
- Compensatory sweating. This condition is one where there is an increase in sweating after the surgical intervention has been effective. This may mean an increase in sweating in the feet, legs or trunk. There is often a very small amount of this postoperatively but it is usually easily tolerated. There may be as much as 10% incidence of compensatory sweating which is uncomfortable for the patient. Of this 10% half of the patients are still happy having had the surgery and the other half are unhappy even to the point of wishing they had never proceeded with the surgery. There is no remedy for compensatory sweating.
A new modality that has benefits in treating isolated axillary hyperhidrosis is Miradry. An ultrasound heating of the sweat glands is performed to destroy their function.