Hyperhidrosis is excessive sweating beyond the physiological need. It usually affects the palms, axillae, and soles and may affect the face, groin, and legs. Symptoms usually appear at puberty and may cause psychological and social problems, as well as occupational and educational difficulties. Between 0.6% and 1% of the general population are affected by hyperhidrosis.(1)
People with palmar hyperhidrosis may be embarrassed to hold hands or be hesitant to shake hands because of having excessively wet palms, often feeling as if they must wipe their palms on their clothing first. People with palmar hyperhidrosis may have difficulty holding onto objects or tools or may have difficulty using computer keyboards, typewriters, or pens. Papers they handle may become wet, and metal objects that they use repeatedly may become rusty. Individuals with palmar hyperhidrosis may find it difficult to play a musical instrument or perform a job requiring the wearing of gloves (eg, food handler, perioperative nurse).
Patients with palmar hyperhidrosis may find that it aggravates eczematous dermatitis, and they may have a predisposition to bacterial and fungal infections. As a result, these people may become withdrawn socially and suffer from low self-esteem. They even may develop psychiatric problems, such as social anxiety disorders.
PHYSIOLOGY OF SWEATING
Sweating is a physiological response to body overheating. It is controlled by the heat regulatory center in the hypothalamus. As the temperature of the environment rises, the body is cooled by vasodilatation of the cutaneous blood vessels and the production of sweat. The sweat then evaporates from the surface of the skin and cools the body.(2)
Sweat glands are tubular structures consisting of a coiled portion deep within the dermis that secretes sweat and a duct through which the sweat travels to the skin. Cholinergic sympathetic nerve fibers on or near the glandular cells elicit the secretion of sweat.
The secretory portion of the gland secretes a fluid called precursor secretion. Concentrations of the constituents of this fluid are modified as the fluid travels through the duct to the pore. When sweat glands are stimulated normally, the precursor secretion passes slowly through the duct where most of the sodium and chloride content is reabsorbed. The concentration of sodium and chloride can fall as low as 5 mEq per liter. This reduces the fluid's osmotic pressure, and most of the water is reabsorbed, thus concentrating other ions in the fluid.
In normal sweating, urea, lactic acid, and potassium ions are very concentrated. When the sweat glands are stimulated strongly by the sympathetic nervous system, large amounts of precursor secretion are formed. Sweat flows so rapidly through the duct that little of the water and slightly more than one-half of the sodium and chloride are reabsorbed, leaving sodium and chloride concentrations as high as 50 to 60 mEq per liter. In these situations, a large loss of sodium chloride and water can occur.(3)
The human body contains two types of sweat glands--apocrine and eccrine. Their location and characteristics differ slightly.
Apocrine sweat glands. The apocrine sweat glands are confined to the axillae, areolas of the nipples, the anogenital area, and the external auditory meatus. They are simple, coiled tubes and are 10 times larger than eccrine glands. The sweat from these glands is milky, contains fat and cholesterol, and can have a strong odor. The apocrine glands begin to function at puberty.
Eccrine sweat glands. The eccrine glands are present on the entire surface of the body but are most numerous on the palms, soles of the feet, face, axillae, and, to a lesser degree, the back and chest. They are coiled tubular glands that open onto the skin through pores. These sweat glands have a rich blood supply and are innervated by the sympathetic nervous system (Figure 1). Nerves stimulate the glands to secrete a plasma-like fluid that is hypotonic (ie, 0.3% to 0.5% sodium chloride) and contains small amounts of potassium, lactic acid, glucose, and urea. Myoepithelial cells, through their contraction, aid in the expulsion of sweat. Acetylcholine and other cholinergic agents increase sweating. Atropine and anticholinergic agents inhibit sweating.(4)
CAUSES OF HYPERHIDROSIS
There are many causes of hyperhidrosis. It can be caused by
* emotional factors,
* a warm environment,
* warm clothing,
* medical conditions (eg, fever, thyrotoxicosis, diabetes mellitus, hypoglycemia, gigantism, and acromegaly, pheochromocytoma, cardiovascular disorders, Hodgkin's disease),
* substance abuse,
* respiratory failure,
* intrathoracic or hypothalamic lesions,
* carcinoid tumors,
* spinal cord injuries, and
* familial dysautonomia (eg, Riley-Day syndrome--an inherited congenital disease occurring mainly in children of Ashkenazic Jewish decent and characterized by a decrease in the number of small unmyelinated autonomic and peripheral fibers that carry pain, temperature, and taste sensations; Nail-patella syndrome--an inherited multisystem disorder characterized by dystrophic nails, hypoplastic or absent patellae, and renal disease).
Hyperhidrosis can be cold-induced, gustatory (ie, stimulated by eating), olfactory (ie, stimulated by strong smells), compensatory (ie, areas of the body become affected by hyperhidrosis after the areas originally affected by hyperhidrosis have been disrupted by surgery or other means), or idiopathic.(5) This article discusses treatment for idiopathic or primary palmar hyperhidrosis.
Treatment should be directed at the underlying cause whenever possible. Affected individuals should wear light clothing, keep the environment cool, and replenish water and sodium chloride lost through sweating. Topical applications of aluminum chloride or aluminum chlorhydroxide may be used to block the openings of the sweat ducts. They must be reapplied frequently (ie, three to four times per day) because excessive sweating unblocks the ducts.
A 20% alcohol solution of aluminum chloride hexahydrate is the most effective topical solution. It blocks the openings to the sweat ducts and should be applied at night, covered with plastic wrap, and washed off in the morning. The skin needs to be dried thoroughly before application. The solution is used daily, weekly, or whenever needed. Skin rashes may result from this treatment; therefore, it should not be applied to freshly shaved skin.(6) Glutaraldehyde and tannic acid also may be used topically, but they can cause skin irritation and brownish skin discoloration.
Iontophoresis can create a temporary blockage of the sweat duct. This is accomplished by directing a mild electric current through the skin in a shallow tap water bath. The electric current shocks the sweat glands, and they stop producing sweat temporarily. The iontophoresis machine is used for 20 minutes a few times per week and may cause sweating to stop for weeks. It can be used at home but is only useful for palms, feet, and axillae.(7) Surgical excision of axillary apocrine sweat glands rarely is performed and may result in infection, hidradenitis, and scarring.(8) Locally applied astringents (eg, potassium permanganate) may provide temporary local relief. Antiperspirant with aluminum salts also may be used to block the ducts.
Anticholinergic medications, such as atropine, oxyphencyclimine, glycopyrrolate, and propantheline bromide, inhibit parasympathetic effects, but these often cause dry mouth, blurred vision, or constipation. These medications usually are taken several times per day. Patients can use them regularly to try to control sweating or only when in situations that cause excessive sweating, such as public speaking or business meetings. Multiple medications and schedules are tried to determine a treatment schedule that works best for the individual patient, depending on the severity of his or her hyperhidrosis.
Botulinum toxin injections sometimes are used for focal hyperhidrosis of the axillae, palms, and feet. Botulinum toxin is a potent neurotoxin that blocks the cholinergic nerve terminals. It is effective only at the site of injection and may be painful and expensive. The injections usually are effective for three to 12 months.(9) In 1998, German neurologists and dermatologists used intracutaneous injections of botulinum toxin on 11 patients with focal hyperhidrosis. Sweating was abolished completely in all patients in three to seven days, but some reactivation of sweat gland function was observed four months after treatment.(10) Biofeedback, hypnosis, and psychotherapy have been tried with variable results. Early in the twentieth century, irradiation of the skin was used to atrophy the sweat glands; however, this treatment has been abandoned.(11)
As sweating is mediated through the sympathetic nervous system, selective sympathectomy appears to be the most effective method to permanently rid patients of palmar hyperhidrosis.(12) Sympathectomy abolishes eccrine sweating in areas supplied by post-ganglionic fibers. In the past, an open surgical technique was used. This generally was performed via transthoracic, supraclavicular, transcervical, transaxillary, or dorsal thoracic surgery. These surgeries involved long hospital stays, large scars, increased morbidity, and long recuperative periods for patients.
The advent of thoracoscopic surgery has made surgical treatment for palmar hyperhidrosis much more attractive. The procedure generally is performed on an outpatient basis, with the patient going home a few hours after the surgery. After the procedure, patients have two one-inch scars hidden in the axillae. At present, patients undergoing this procedure at New York Presbyterian Hospital, New York, have gained relief from hyperhidrosis. Patients are referred by dermatologists or they refer themselves to this program. Many patients have learned about this procedure on the Internet or from other patients who have benefited from the surgery.
The surgeon sees and evaluates the patient while performing a physical examination and taking a clinical history. He or she explains the surgical procedure, potential complications, and side effects to the patient and obtains written informed consent for the surgery and a consent for the administration of blood products if necessary. Patients who typically undergo this procedure are in their twenties and thirties. They find this condition to be embarrassing and believe that their lives have been affected negatively by the condition. The surgeon schedules the patient for elective surgery and sends him or her to the preadmission testing area of the hospital for blood tests (eg, complete blood count; prothrombin time; partial thromboplastin time; eosinophil sedimentation rate; sodium, potassium, chloride, glucose, and carbon dioxide levels; blood urea nitrogen; creatinine; calcium; thyroid profile). The thyroid profile is drawn to rule out thyroid disease as a cause of the hyperhidrosis. A chest x-ray and electrocardiogram also are performed. The anesthesia care provider interviews the patient, explains his or her plans for anesthesia, and obtains informed consent. The anesthesia care provider instructs the patient not to eat or drink after midnight the night before surgery; however, no other special preparations are needed.
On the day of surgery, the patient arrives at the ambulatory surgery unit (ASU) one and one-half hours before surgery is scheduled. In the ASU, the patient changes into a hospital gown, and the admitting nurse takes vital signs and checks the chart for a history and physical examination, blood work, and signed consent forms. The nurse performs a systems assessment of the patient that includes
* the patient's general health,
* any previous surgeries,
* existing medical conditions or disabilities,
* routine medications, and
* pregnancy status, if applicable.
He or she questions the patient about allergies, including those to medications, food, and latex. The nurse verifies that the surgery will be bilateral and that the patient will accept a blood transfusion, if necessary. The nurse asks the patient to remove all jewelry, dentures, hearing aides, contact lenses, and any other prostheses. Hearing or sight impaired patients are allowed to retain their heating aids or glasses until induction. The nurse verifies that the patient has an escort to take him or her home after recovery from anesthesia. Table 1 provides a nursing care plan.
The perioperative circulating nurse greets the patient, explains the anticipated procedures, and transports the patient to the OR where the anesthesia care provider inserts an IV line and an arterial line to continuously monitor vital signs during the surgical procedure. The anesthesia care provider administers a general anesthetic and intubates the patient with a double-lumen endotracheal tube. The double-lumen tube allows the anesthesia care provider to selectively ventilate one lung while the other lung is deflated. This allows the surgeon to better see the surgical field.
Surgical team members place the patient in the supine position with his or her arms extended at right angles on padded arm boards to allow a transaxillary incision (Figure 2). Care is taken to not extend the patient's arms past 90 degrees, which could cause nerve damage. The nurse ensures that the safety belt is in place, pads any bony prominences, inspects the patient's skin for problems, and applies an electrosurgical dispersive pad. He or she shaves the patient's axillae and preps the chest and axillae with an antimicrobial solution. The surgeon and scrub person drape the patient using sterile split sheets and an iodophor-impregnated adhesive drape.
The surgeon, assistant, and scrub person all stand on one side of the patient to perform the surgery on the initial side. The circulating nurse positions a monitor on each side of the patient to allow the surgeon to view the surgical field from either side. The scrub person and circulating nurse attach the camera and light source to the thoracoscope and the unipolar and bipolar cords to the electrosurgical unit. The surgeon asks the anesthesia care provider to deflate one of the patient's lungs, makes a one-inch transverse incision in the axillae between the patient's second and third ribs, and inserts a disposable. 11.5-mm thoracic port into the incision (Figure 3). The 11.5-mm port accommodates the 0-degree, 5-mm thoracoscope, as well as any instruments used, through a single incision.
The surgeon then identifies the sympathetic nerve chain at the T-2 level (Figure 4). He or she opens the pleura in the posterior thoracic cavity using an endoscopic scissor (Figures 5 and 6), grasps the nerve between the T-2 and the T-3 levels with an endoscopic bipolar forcep (Figure 7), and cauterizes it (Figure 8).
The surgeon removes the disposable thoracic port, inserts a 20-Fr thoracic catheter into the thoracic cavity, closes the soft tissues, and submerges the other end of the chest tube in a bowl of saline (Figure 9). He or she then asks the anesthesia care provider to reinflate the patient's lung and sustain lung expansion at 30 mm Hg of pressure. As the patient's lung reexpands, air is forced out of the thoracic cavity, causing bubbling in the bowl of saline. When the bubbling stops, the surgeon quickly removes the catheter, and closes the remainder of the incision. A sterile adhesive bandage strip is placed on the incision. The surgeon, assistant, and scrub person then move to the patient's opposite side and repeat the procedure.
The anesthesia care provider awakens and extubates the patient in the OR and helps surgical team members transport him or her to the postanesthesia care unit (PACU) for recovery. In the PACU, nurses observe the patient for any sign of pneumothorax (eg, pain on one side, difficulty breathing, uneven breath sounds in the chest). A chest x-ray is taken in the PACU to ascertain that no pneumothorax has occurred. The surgeon gives the patient a prescription for acetaminophen with codeine to be taken every four hours if needed for pain and instructs the patient to keep the incision dry. The patient's activities are limited only by discomfort, but he or she is advised to take a few days off from work. The nurse discharges the patient with instructions to return to the surgeon's office for a postoperative check in one week.
The patient is warned preoperatively of possible complications, including
* bleeding, which would require the surgeon to perform a small thoracotomy incision and necessitate a possible overnight stay;
* compensatory sweating, usually in the feet, axillae, or trunk; and
* Homer's syndrome, which occurs because of damage to the sympathetic nerve fibers of the face and results in an ipsilateral small pupil, dry face, and slight ptosis (ie, drooping) of the eyelid.(13)
Mr R is a 34-year-old man with palmar hyperhidrosis. His occupation entails installing specialized components in computers. Computer components may not be exposed to moisture, which can damage them. He feels uncomfortable shaking hands at business meetings because of his sweaty palms. He feels uncomfortable in his sexual life, although his wife says she does not mind. His nine-year-old daughter often says to him, "Ugh, Daddy, your hands are always wet."
Mr R tried an aluminum chlorhydroxide product but found he could not handle computer components with particles of aluminum chlorhydroxide on his hands. He also tried iontophoresis, but he says with a full-time job, a nine-year-old daughter, and a three-month-old son, he could not find the time to soak his hands in a bath for 30 to 60 minutes every day for seven days. He found an Internet site from a Swedish facility that introduced him to thoracoscopic sympathectomy, and he was referred to a physician by his father-in-law, who is a dermatologist. Mr R decided to have the elective bilateral thoracoscopic sympathectomy because he felt hampered in his professional life and embarrassed in his personal life. He is a healthy male with no previous surgical history. He has no cardiac disease, respiratory symptoms, endocrine symptoms, genitourinary problems, musculoskeletal problems, or other neurological problems. His surgeon tested him for abnormal thyroid function, which can cause hyperhidrosis, and all tests were within normal limits. Mr R denied tobacco and alcohol use.
Nurses in the ambulatory surgery department admitted Mr R for a bilateral thoracoscopic sympathectomy without complications. The surgery lasted one and one-half hours. Mr R emerged from general anesthesia without incident and was transferred to the PACU. When interviewed in the PACU, he was very pleased that his palms no longer felt sweaty. He was sure that his daughter and wife would be thrilled. He was delighted that he had only a one and one-half inch incision in each axilla and little discomfort. Mr R left for home later that afternoon with his wife.
When more conservative therapies fail, patients may benefit from undergoing thoracoscopic sympathectomy for primary palmar hyperhidrosis. One study of 400 patients found that those who underwent sympathectomy showed 100% immediate relief from palmar sweating. The posterior surgical approach used on these patients, however, lasted two to three hours and involved a four- to five-day hospital stay.(14) The 45 patients who underwent the procedure at the New York Presbyterian Hospital between 1998 and 2000 received immediate relief of palmar sweating. Their surgeries lasted one and one-half to two hours, and all but one of the patients returned home a few hours after the procedure. This patient experienced bleeding that necessitated a mini-thoracotomy and an overnight hospital stay. Thorocoscopic sympathectomy is safe and effective, and the result is a life-changing experience for patients.
THORACOSCOPIC SYMPATHECTOMY FOR PALMAR HYPERHIDROSIS
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(1.) A K C Leung, P Y H Chan, M C K Choi, "Hyperhidrosis," International Journal of Dermatology 38 (August 1999) 561-567.
(2.) C B Wegner, "The regulation of body temperature," in Medical Physiology, R A Rhoades, G A Tanner, eds (Boston: Little, Brown, and Co, 1995) 587-613.
(3.) A C Guyton, J E Hall, "Body temperature, temperature regulation, and fever," in Textbook of Medical Physiology, ninth ed (Philadelphia: W B Saunders Co, 1996) 914-915.
(4.) Leung, Chan, Choi, "Hyperhidrosis," 561-567.
(7.) J C Tabet, J W Bay, M Magdinec, "Essential hyperhidrosis: Current therapy," Cleveland Clinic Quarterly 53 (Spring 1986) 83-88.
(8.) Leung, Chan, Choi, "Hyperhidrosis," 561-567.
(9.) M Heckmalm et al, "Follow-up of patients with axillary hyperhidrosis after botulinum toxin injection," Archives of Dermatology 134 (October 1998) 1298-1299.
(10.) M Naumann et al, "Focal hyperhidrosis: Effective treatment with intracutaneous botulinum toxin," Archives of Dermatology 134 (March 1998) 301-303.
(11.) Tabet, Bay, Magdinec, "Essential hyperhidrosis: Current therapy," 83-87.
(12.) T S M Chiou, S C Chen, "Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis," British Journal of Surgery 86 (March 1999) 45-47.
(13.) H J Chen, D Y Shih, S T Fung, "Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis," Archives of Surgery 129 (June 1994) 630-633.
(14.) Heckmann et al, "Follow-up of patients with axillary hyperhidrosis after botulinum toxin injection," 1298-1299.
Gloria M. Allen, RN, BSN, CNOR, is a perioperative nurse and thoracic surgery team leader at the New York Presbyterian Hospital, New York.
The author wishes to thank Kenneth M. Steinglass, MD, FACS, FCCP, director of thoracic surgery; Mark E. Ginsburg,, MD, FACS, FCCP, associate director of thoracic surgery; Lyall A. Gorenstein, MD, FRCS, thoracic surgeon; and Charles Reidel, MD, neurosurgeon, at the New York Presbyterian Hospital, New York, for their assistance in preparing this article. The author also thanks Rebekah J. Allen, Larchmonts, New York, for her help with photography and artwork.
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