1. Hyperhidrosis Dr Abbas Pardakhty 2011 Kerman Faculty of Pharmacy 2.
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Transcript of 1. Hyperhidrosis Dr Abbas Pardakhty 2011 Kerman Faculty of Pharmacy 2.
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Hyperhidrosis
Dr Abbas Pardakhty2011
Kerman Faculty of Pharmacy
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Sweat Glands
The human body has 2-5 million sweat glandsTwo main types:
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ECCRINEAPOCRINE
Source: www.sweathelp.org
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Eccrine Sweat Glands
Approximately 3 million eccrine sweat glands
Secrete a clear, odorless fluidAid in regulating body
temperatureAreas of concentration:
Facial, plantar, and axillae
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Source: www.sweathelp.org
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Apocrine Sweat Glands
Inactive until pubertyProduce thick fluid
Secretions come in contact with bacteria on the skin
and produce characteristic “body odor”
Found in axillary and genital areas
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Source: www.sweathelp.org
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Sweating
The hypothalamus serves as the thermoregulatory center
It controls both blood flow and sweat output to the skin’s surface
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Source: www.sweathelp.org
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Sweating
The hypothalamus can be triggered by:
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EXERCISE
TEMPERATURE CHANGE
STRESS
HORMONESSource: www.sweathelp.org
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Sweating
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Once triggered, the hypothalamus sends messages down the
spinal cordvia neurotransmitters.
Source: www.sweathelp.org
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SweatingThe neurostransmitters travel down the spine
via ganglion or sympathetic nerves
These ganglion travel to nerves, which reach the skin’s surface
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Photo used with permission: The Whiteley Clinic,2007
Source: www.sweathelp.org
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Neurotransmitters
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Neurotransmitters act as “vehicles,” transmittinginformation from the hypothalamus to the skin’s surface.
Photo used with permission: The Whiteley Clinic, 2007
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NeurotransmittersThe neurotransmitters can “exit” at various
places along the spinal cord.
The “exit” determines the location of skin innervation.
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Spinal Cord Innervations
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T2 – T8 innervate the skin of the upper limbs
T2-T4 innervatethe skin of the face
T4-T12 innervate theskin of the trunk T10-T12 innervate the skin
of the lower limbs
Source: www.sweathelp.org
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Neurotransmitters
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Acetylcholine innervates
Eccrine Sweat Glands
Catecholaminesinnervate
Apocrine Sweat Glands
Source: www.sweathelp.org
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Sweating
Once innervated, the apocrine and eccrine glands will produce.…
SWEAT!
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Source: www.sweathelp.org
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What is Hyperhidrosis?
•Sweating that is more than required to maintain normal thermal regulation
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Sweating Nomenclature
•Areas: Focal, regional, generalized•Symmetry: Symmetric or asymmetric•Classification: Primary vs. secondary•Type of sweating: Anhidrosis, euhydrosis,
hyperhidrosis
16Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
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Hyperhidrosis
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Causes of Generalized Hyperhidrosis
Usually secondary in nature•Drugs (Venlafaxine, ...), toxins, substance abuse•Cardiovascular disorders•Respiratory failure•Infections•Malignancies
•Hodgkin’s, myleoproliferative disorders, cancers with increased catabolism
•Endocrine/metabolic disorders•Thyrotoxicosis, pheochromocytoma, acromegaly, carcinoid tumor,
hypoglycemia, menopause
• Rarely Idiopathic / Primary HH
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Causes of Localized Hyperhidrosis
•Usually Idiopathic / Primary•Social anxiety disorder•Eccrine nevus•Gustatory sweating•Frey syndrome•Impaired evaporation•Stump hyperhidrosis after amputation
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Idiopathic (Primary) Focal Hyperhidrosis
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Mean Age of Onset
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Diagnosis of Primary Focal Hyperhidrosis
•Focal, visible, excessive sweating of at least 6 months duration without apparent cause with at least 2 of
the following characteristics :–Bilateral and relatively symmetric–Impairs daily activities–Frequency of at least one episode per week–Age of onset less than 25 years–Positive family history–Cessation of focal sweating during sleep
22Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
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Diagnostic Work-up
•History–Age of onset–Location–Trigger factors–Review of symptoms
•Physical exam•Laboratory evaluation
–Gravimetric– 1° research tool–Starch iodine – defines area of disease
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Starch iodine test, with the darkened area showing location of excessive sweating
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Axillary Sweat Production
1° hyperhidrosis patients healthy controls
346.0
Hund et al. Arch Derm 2002;138(4):539-41
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DLQI Total Scores and Ranges by Dermatological Disease/Condition
Diseases with DLQI Scores 10 or Greater
DiseaseDLQI Score (baseline)
Hyperhidrosis palms18–8.8Hyperhidrosis axillary17–10
Eczema (inpatient)16.2Focal hyperhidrosis (general)15.5–9.2
Psoriasis (inpatient)13.9Hyperhidrosis forehead12.5
Atopic eczema12.5–5.8Psoriasis (outpatient)11.9–4.51
Contact dermatitis10.8Pruritus10.5–10
25 Spalding et al. Value in Health 2003;6(3):242(abstract)
Scores range from 0 to 30, with 30 indicating the worst quality of life.
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Summary
Primary Focal Hyperhidrosis is a separate and unique disease
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•Bilateral & symmetricBilateral & symmetric•Axilla, palms, soles, craniofacialAxilla, palms, soles, craniofacial•Onset in childhood and Onset in childhood and adolescenceadolescence•Significant impact on quality of Significant impact on quality of lifelife•Effective therapiesEffective therapies
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TreatmentTreatment
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Available Treatments
•Topical agents•Iontopheresis•Systemic agents
–anticholnergic
•Botulinum toxin•Surgery
–Local excision/currettage–Thoracic sympathectomy
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Treatment Response
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the first treatmentoption to begin!
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Topical TreatmentFirst line treatment
Aluminum Chloride Hexahydrate antiperspirant of choice
Most beneficial for axillary hyperhidrosis
Can be used for plantar and palmar
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Photos used with permission:www.feelbest.com
Hornberger, 2004
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Topical Treatment:How Does it Work?
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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
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Topical TreatmentSweat production never
ceases, the gland is simply plugged
Sweating will return as the skin undergoes regeneration
or shedding
Therefore…topical treatment is NOT a cure!
33Hornberger, 2004
Photo used with permission:Neurosurgical Medical Clinic, Inc
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Topical Treatment:How to Use
Best to apply before bedtimeAllow to remain on skin for 6 – 8 hours
Apply every 24 – 48 hours until sweating diminishes
Maintenance applications needed every 1-3 weeks
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Hornberger, 2004
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Topical Treatment: Pros and Cons
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Non – invasiveItching and burning of skin
at application site&Time-consuming&Temporary reliefHornberger, 2004
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Topical Treatment:Effectiveness
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66.6% stop using dueto the “CONS”
Naumann, Hamm, & Lowe, 2002
88% effective forAxillary Hyperhidrosis
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the second treatmentoption!
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Systemic TreatmentAnticholinergics can be used in treating
hyperhidrosisMost effective for cranio-facial hyerhidrosis
Robinul – drug of choice
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Haider & Solish, 2004
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Oral Glycopyrrolate (Glycopyrronium bromide)
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How Does it Work?
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Anticholinergic
Blocks Acetylcholine transmission
Eccrine sweat glands no longer stimulated
Sweat production ceases!
Haider & Solish, 2004
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Anticholinergics
Long term therapy is requiredMajor side effects:
Dry mouthDry eyes
Constipation Blurred vision
Difficulty with urination
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Thomas, Brown, & Vafaie, 2004
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Anticholinergics
Limited use in treating hyperhidrosis
Only 21% effective
69.7% stop using due to side effects
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Hamm, Naumann, & Kowalski, 2006
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Topical anticholinergics
•glycopyrronium bromide as 1 and 2% cream or roll-on solution
•Topical hyoscine as 0.25, 1, or 3% solution or cream also gave control of sweating, but was associated
with a much higher incidence of side-effects .•Patients with diabetic gustatory sweating have also
noted a reduction in the frequency and severity of episodes after applying glycopyrronium 0.5% cream
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the third treatmentoption!
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Iontophoresis•Used for palmar and
plantar hyperhidrosis
•Passage of direct electrical current onto skin’s surface
•Device can be purchased for home use
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Photo used with permission: Beast Psoriasis, 2006
Thomas, Brown, & Vafaie, 200 4
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Iontophoresis
Sit with hands or feet in shallow tray of water
Allow 15 – 20 milli-amps of electrical current to pass
through waterUse for 10 days, 30 minutes
each dayMaintenance therapy needed
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Photo used with permission: Beat Psoriasis, 2006
Thomas, Brown, & Vafaie, 2004
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Iontophoresis:Mechanism of Action
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WATER
+
ELECTRICTY
= Thickening of skinAnd
Blocked sweat flow
www.sweathelp.org
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Iontophoresis
Side effects:Skin irritation
Skin burnsVesicle formation
Time consuming treatment
80% effective for palmar and/or plantar hyperidrosis
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Photo used with permission: Beat Psoriasis, 2006
Thomas, Brown, and Vafaie, 2004
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
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Botox
Botox injections can be used to treat axillary, palmar, and plantar hyperhidrosis
Analgesic applied prior to injectionNerve block applied to ulnar or radial nerve
prior to palmar injection
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Haider & Solish, 2004
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Botox
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Botox blocks the release of acetylcholine at the site of the neuromuscular junction.
Sweat glands are not stimulated, and sweat production ceases
Site of blockagePhoto used with permission: Whiteley Clinic, 2007
Haider & Solish, 2004
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BIOCHEMICAL PROCESS OF VESCICULAR FUSION BLOCKAGE
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Botox
Starch Iodine test done prior to injection
Delineates areas of excess sweating with
black-purple discoloration of the skin
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Photo used with permission: Eisenach, Atkinson, & Fealey, 2005
Haider & Solish, 2004
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Botox
Cons:Very painful to the
palms and soles of feetExpensive: $1400-$1600
per treatment
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Pros: Lasts 6-7 months 90% effective
Thomas, Brown, & Vafaie, 2004
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
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Local ExcisionUsed only for axillary hyperhidrosis
Starch Iodine test done prior to excision
Performed under local anesthesia Vasoconstrictor applied to axillary
regionSmall incisions made
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Eisenach, Atkinson, Foley, 2005
Photo used with permission:Gasparri, 2006
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Local Excision
Eccrine sweat glands removed through:Liposuction – suctioned out
Curettage – scraped outExcision – cut out
Incisions suturedPain and bruising to excision site
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Eisenach, Atkinson, & Fealey, 2005
Photo used with permission:Gasparri, 2006
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Local Excision
•Starch Iodine tests done post excision show 80% - 90% decrease in sweating
•Has a potential for scarring
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Eisenach, Atkinson, & Fealey, 2005
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Treatment Options
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Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
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Endoscopic Thoracic Sympathectomy (ETS)
Last treatment option
PERMANENT
Surgery performed under general anesthesia
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Haider & Solish, 2004
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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
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ETS
Small incision made laterally under each axillaIncision made through intercostal space
Surgery can be performed on outpatient basis However, some patients remain in hospital for
one night
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ETS
Ganglion located along the sympathetic chain
Ganglion formed below each rib
Ganglion can be divided = sympathicotomy
Ganglion can be removed = sympathectomy
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ETSGanglion at T2 and T3 = palmar hyperhidrosisGanglion at T3 and T4 = axillary hyperhidrosis
Ganglion at L2-L4 = plantar hyperhidrosis
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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
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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!
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ETS: Side Effects
Surgical complications:Hemo-pneumothorax requiring chest tube
placement – 1%Atelectasis (collapse of the lung)
Intercostal neuralgia – 1%Horner’s Syndrome – 1%
Compensatory Sweating – 60%
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Horner’s Syndrome
Stellate ganglion – fusion of C8 and T1Innervates 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
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Horner’s Syndrome
Signs and SymptomsUnilateral upper eyelid ptosis
Pupil constrictionFacial anhidrosis
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Treatment Option Review
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Hyperhidrosis
Topical Treatment
Botox
Iontophoresis
Local Excision
Iontophoresis
Botox
ETS
AXILLARY PALMOPLANTAR
Hornberger, 2004
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Treatment Option Review
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Photo used with permission: The Whiteley Clinic, 2007
Systemic – blocks acetylcholine