DON’T SWEAT IT

Hy­per­hidro­sis: The treat­ment op­tions for ex­ces­sive sweat­ing

201 Health - - News - WRIT­TEN BY AMELIA DUG­GAN

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.

PO­TEN­TIAL COM­PLI­CA­TIONS

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.

NON-SUR­GI­CAL TREAT­MENTS

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

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