DON’T SWEAT IT
Hyperhidrosis: The treatment options for excessive sweating
Hyperhidrosis: The treatment options for excessive sweating
Shaking hands. It’s an everyday part of life. Now imagine that as you extend your hand to take another’s you’re aware that it is full of sweat. You are embarrassed and you withdraw. That may happen to anyone on an occasional basis – like a much-anticipated date or job interview, but for those who suffer from hyperhidrosis, it is an everyday occurrence and cause for often debilitating social anxiety.
Palmar hyperhidrosisis is considered the worst of the condition because of the psychological impact. Typical patients are in late teens or early 20s and they’re starting to date – or going on job interviews and have to shake hands. Many doctors know little about this condition. Hyperhidrosis, in its various forms, actually affects about 6 percent of the American public.
Dr. Robert Korst, thoracic surgeon and director of The Valley Hospital’s Hyperhidrosis Center, sees many patients who suffer with various forms of hyperhidrosis – excessive sweating of the palms and soles, armpits, face and even back. Korst has achieved great success with sympathectomies – a minimally invasive surgical procedure which includes two small incisions in the armpits.
“This procedure is done with a general anesthetic and patients are discharged the same day,” Korst says. “Patients usually take a long weekend or a few days off and then go back to normal activity.”
Through the incisions, a telescopic camera about the size of a large spaghetti noodle is inserted into the body, Korst says. The sympathetic chain of nerve ganglia in the chest is located, and then the particular level of the chain that the doctor wishes to interrupt is identified, which depends on where the hyperhidrosisis is. Next, Korst explains that he divides the chain at the appropriate level – “it takes about 10 minutes” – and then he puts a stitch in each incision in both armpits.
“Palmer sufferers are the most gratifying for me because they have the most difficult time coping with the condition,” he says. “We have a 98 percent success rate and they are the happiest people after the surgery. Armpit sufferers also have a high success rate.”
Patients spend about 90 minutes in recovery, during which time they’ll have a chest X-ray done. If it looks good they are cleared to go home. Patients are discharged with a prescription for
Tylenol with codeine.
“Any time you make an incision, there’s going to be discomfort because you’re going into the chest, which moves when one breathes,” Korst adds.
Korst says that the results of the procedure are immediate so patients in the recovery room will be aware of the change.
“The result of surgical intervention for the right patient is outstanding,” he says. “I like to operate on the more severe cases, including those patients who have tried other approaches that have failed. They are the most happy with the outcomes.”
Since he began performing sympathectomies in 1998, Korst has completed hundreds of successful procedures and believes that the minimally invasive approach has revolutionized the intervention.
Compensatory sweating can occur post-surgery for some patients. At times, when it is normal to sweat, one may notice that they will sweat more than they used to in an alternate area – lower back, buttocks or belly. It’s hard to predict which individual patient will get this, but patients who have had sympathectomies for sweating on the face and head are more likely to get compensatory sweating.
“Consider a scenario of an air traffic controller who was going to lose his job because his earphones kept falling off,” Korst says. “He did have some compensatory sweating but he could hide it. Same holds true for the person who has to give a presentation and has to repeatedly towel off his face. Compensatory sweating in a place that isn’t visible is considerably the lesser of two evils.”
Korst believes it is important to point out that surgery is not an option for the feet. He also does not believe that antidepressants are a good therapy for hyperhidrosis.
“These medications are not a good idea because they have no impact. Most of the stress is caused by hyperhidrosis, not the other way around,” he says. “It can start in childhood, but the usual scenario is in teens and it doesn’t go away. Kids don’t outgrow it.
While the sympathectomy has high success rates, not all patients choose a surgical intervention right from the start – particularly with younger patients.
Dr. Brook Tlougan, a pediatric dermatologist with Hackensack University Medical Center and Instructor in Clinical Dermatology at Columbia University Medical Center, sees children who are just beginning to face the impact of the condition.
“Hyperhidrosis can have a crippling effect on teens,” Tlougan says. “The extreme cases can be socially embarrassing and cause the children to withdraw from typical high school activities.”
Tlougan says that it’s like a Pavlovian response, in that the more the teens worry about sweating, the more they sweat. The thought triggers the response and it’s like a vicious cycle. Most people don’t understand how the condition presents itself. Tlougan outlines a sequence of non-surgical interventions that deliver varying degrees of success. “For some sufferers, an over-the-counter aluminum chloride based product is enough,” Tlougan says. “Others may require a prescription-strength topical aluminum chloride hexahydrate-based antiperspirant.”
With varying results, iontophoresis uses a device to deliver currents to the hands or feet with tap water as a conductive medium. Little plugs of keratin develop into the sweat glands to plug up the ducts. The effect can last up to four-to-six weeks. Iontophoresis is safe, but the response is variable between patients. A major side effect is dryness – sometimes it can be severe and people have too much of a response. It can be painful in some cases if a patient has high sensitivity to the electrical current, but this is not a typical response.
Next is Glycopyrrolate, an oral medication, designed to treat ulcers. Tlougan says that Glycopyrrolate’s mechanism of action is to block the neurotransmission of the molecule responsible for the production of sweat. It can also cause dry eyes and dry mouth, and some bowel and bladder dysfunction, which can make it intolerable to patients, but it can reduce sweating overall with few long-term issues.
UP LAST IS BOTULINUM TOXIN A.
“Quite effective for armpit sweating, as well as palms and soles” Tlougan says. “Botulinum toxin is a popular treatment option and has an excellent safety profile. It lasts three-to-six months depending on the individual and is repeated as necessary.
“We’ve been talking to the manufacturers. They often help to get it approved through the insurance companies, but the approval process does take some time.”
“Palmer sufferers are the most gratifying for me because they have the most difficult time coping with the condition. We have a 98 percent success rate and they are the happiest people after the surgery. Armpit sufferers also have a high success rate.”
DR. ROBERT KORST THORACIC SURGEON AND DIRECTOR OF THE VALLEY HOSPITAL’S HYPERHIDROSIS CENTER