Hyperhidrosis

Hyperhidrosis involves excessive activity of the underarm sweat glands (eccrine glands) associated with sympathetic overactivity,exacerbated by mental and emotional stimuli. As a result, an excessive amount of sweat, exceeding 125 mg of sweat secreted within 5 minutes, is produced.

Histopathological examination of hyperactive glands reveals no abnormalities. The onset of the disease occurs mostly in puberty. Apart from the axillary region, the disease may affect hands and feet, and two forms of the disease – axillaris and palmoplantaris –may exist simultaneously in one patient. Due to the unpleasant disease symptoms, both for the patient and patient's environment, a significant impairment of professional and social activity often occurs.

Currently, various treatments for excessive sweating are available:

Topical formulations, including formaldehyde, aluminum sulphate and aluminum-zirconium saltare used but it appears that the most efficient agent is 20% buffered aluminum chloride hexahydrate in anhydrous ethanol appliedunder occlusion overnight. Commercial antiperspirants are usually ineffective. Water iontophoresis, also with the addition of anticholinergics, is one of the treatment options, albeit difficult to use in the axillary region. Some authors have reported good results of psychotherapy. The commonly used medications, namely: anticholinergics (glycopyrronium,bornaprine,HCl), calcium channel blockers, analgesics (propoxyphene), antihypertensives (clonidine) or sedatives may inhibit sweating but only at doses which entail side-effects.

Since 1996, the use of botulinum toxin A injections has been gaining ground in the treatment of hyperhidrosis. Botulinum toxin A (Botox®) at a dose of 50 to 70 UI per armpit is injected subcutaneously at 15 - 20 locations separated from each other by a gap of 1-2 cm. The first effects of the treatment are visible after a week, whereas a complete suppression of the sweat glands occurs after a month. The main disadvantage of this method is that the beneficial effects wear off after 4 - 9 months and usually after that time it is necessary to repeat the procedure.

Because of the risk associated with surgical treatment, it is recommended to try other methods first. There are many ways of treating hyperhidrosis surgically. Until the mid 60s,sympathectomy of the 2nd or 3rdthoracic ganglion was performed. Later on it was replaced by the improved method of endoscopic transthoracic sympathectomy. These methods had proven to be more effective for managingthe excessive hand sweating than the underarm sweating. Today, diagnosis of axillary hyperhidrosis is an indication for the underarm-targeted procedure. Many types and modifications of this procedure have been described. In the first half of the 60s, Hurley and Shelley reported the first operation of the sweat glands removal with priormapping the hyperhidrotic glands with Minor starch-iodine test. The central part of the revealed hyperhidroticarea was excised with the traverse spindle-shaped incision of 5 x 2 cm in size, the adjacentskin was undermined and the sweat glands were removed from the underside. It is a convenient method of removing large apocrine glands visible to the naked eye but at the same time it eradicates the smaller, eccrine glands intermingled with apocrine glands. A similar procedure, though involving a M-or W-incision, was described by Eldh-Fogdestam. The Skoog-Thyresson technique involved a wide excision of glands of the entire axillary fossa following the incision and uplifting four skin flaps.

Wide excision of the skin in axillary fossa with subsequent Z-plasty is recommended in the Bretteville-Jensen method. In the most severe cases, some authors indicate a complete removal of axillary skin withsubsequent skin grafting. All surgical methods involving the excision and undermining the skin may result in numerous complications, such as haematomas, infections, wound dehiscence, necrosis of the skin, unsightly scars.

The concept of the subcutaneous destruction of sweat glands without wide incision and skin undermining was first explored in procedures carried out by means of subcutaneous tissue shaver or curettes. After theintroduction of tumescent infiltration with large volumes of solution and liposuction cannulas, these procedures became easier to perform and less traumatic for patients. Presently, subcutaneous curettage of the underarm by means of liposuction devices is increasing in popularity. It is considered to be a straightforward procedure, almost devoid of complications and providing a long-lasting effect.

On the basis of the sweat glands secretion observation carried out several minutes prior to the procedure, the area of hyperhidrosis is delineated. All procedures are performed under tumescent local anaesthesia (100-250 ml of Klein’s tumescent solution) administered under the axillary skin by a rotary infusion pump and a core needle. Then, liposuction cannulas with diameters of 3-4 mm and 1 or 2 lateral holes are inserted through three skin incisions of approx. 3-4 mm in length. The treatment of both underarmstakes 30 to 45 minutes.

Following the retraction of the cannulas, the surgical site is coveredwith antibiotic ointment and highly absorbent wound dressing and then compressed with an elastic adhesive bandage. Patients are instructed to refrain from abducting the arms. The same wound dressing procedure is repeated the following day and later on only dressings covering the incision sites are used.

The patients tolerate the procedure well and in the postoperative period they suffer only minor ailments. After 7 days, the wounds are completely healed, and a return to full fitness is observed within 2 - 7 days. Rare complications include haematomas, temporary hardening of the skin and subcutaneous tissue, partial necrosis of the skin.

Many doctors and patients are unaware of the existence of effective treatments foraxillaris hyperhidrosis offered by modern dermatosurgery. Liposuction of axillary fossa carried out under tumescent local anaesthesia appears to be a simple and effective method of treatment. Complications are rare and minor, and the method is well tolerated by patients. Postoperative scars are small and practically invisible in this location and the risk of scarring developmentimpairing motor functions is low. Infections are rare, wounds heal quickly. The use of tumescent infiltration significantly reduces the risk of haematoma and can almost completely eliminate pain in the postoperative period. According to some authors the beneficial effectlasts at least 24 months, which is much longer than in the case of botulinum toxin A injection.It seems that this procedure is more increasingly recognised as a highly effective method, which can relieve the patient from suffering a lifetime condition in a one-time procedure.

In spite of the reported complications, the method ofsubcutaneous suction seems to be much more conservative and associated with fewer complications compared with conventional surgical techniques involving skin excision and undermining the adjacent tissue.

 

References:

1. Hurley HJ: Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. [in] Dermatologic surgery, principles and practice, RK Roenigk, HH Roenigk (ed),Marcel Dekker, New York, Basek, Hong Kong 1996:623-645

2. Morgan BDG: Benign skin lesions. Congenital deformities of the neck. [in]: Operative plastic and reconstructive surgery, JN Barron, MN Saad (ed), Churchill Livingstone Edinburgh, London, Melbourne, New York 1980:557-579

3. Harahap M: Management of hyperhidrosis axillaris. J Dermatol Surg Oncol 1979;5:223-225

4. Holze E: Therapy of hyperhidrosis. Hautarzt 1984;35:7-15

5. Ambroziak M, Kwiek B, Langner A: Leczenie nadmiernej potliwości. Dermatologia Estetyczna 2002; 2: 56-64

6. Bushara KO, Park DM, Jones JC, Schutta HS: Botulinum toxin- a possible new treatment for axillary Hyperhidrosis.Clin Exp J Dermatol 1996;21:276-278

7. Carruthers A, Caruthers J:Botulinum A exotoxin.in:RS Narins(ed),Cosmetic Surgery, Marcel Dekker, New York, Basel 2001:333-353

8. Odderson IR: Hyperhidrosis treated by botulinum A exotoxin.Dermatol Surg 1998;24:1237-1241

9. Schnider P, Binder M, Kittler H, Birner P, Starkel D, Wolff K, Auff E: A randomized, double-blind, placebo-controlled trial of botulinum A toxin for severe axillary hyperhidrosis. Br J Dermatol 1999;140:677-680

10. Salmanopoor R, Rahmanian MJ: Treatment of axillary hyperhidrosis with botulinum-A toxin. Int J Dermatol 2002; 41:428-430

11. Naumann M, Lowe NJ, Kumar CR, Hamm H: Botulinum toxin type A is a safe and effective treatmant for axillary hyperhidrosis over 16 months: a prospective study. Arch Dermatol 2003;139:731-736

12. Naumann M, Lowe NJ: Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ 2001;323:596-599

13. Odderson IR: Long-term quantitative benefits of botulinum toxin type A in the treatment of axillary hyperhidrosis. Dermatol Surg 2002; 28:480-483

14. Landes E, Kappesser HJ: Surgical treatment of axillary Hyperhidrosis. Fortschr Med 1979;97:2169-2171

15. Hasche E, Hagedorn M, Sattler G: Subcuteneous sweat gland suction curretage in tumescent local anesthesia in hyperhidrosis axillaries. Hautarzt 1997; 48:817-9

16. Lillis, PJ: Tumescent Anesthesia. [in]: Dermatologic surgery, pinciples and practice RK Roenigk, HH Roenigk (ed), Marcel Dekker, New York, Basel, Hong Kong 1996, 41-52

17. Proebstle TM, Schneiders V, Knop J: Gravimetrically controlled efficacy of subcorial curettage: a prospective study for treatment of axillary hyperhidrosis. Dermatol Surg 2002 ;28:1022-1066

18. Klein JA: The pharmacology of tumescent liposuction.[w]: Cosmetic Surgery, RS Narins (red), Marcel Dekker, New York, Basel 2001; 443-456

19. Field LM: Botox for a lifetime or tumescent axillary liposuction and curettage-once. Dermatol Surg 2003 ;29:317

20. Field LM: Tumescent axillary liposuction and curettage with axillary scarring: not an important sequela. Dermatol Surg 2003;29:317