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It is only natural that our body sweats to help it stay cool, especially at warmer temperatures or during times of exercise. Our sympathetic nervous system aids in regulating this process, making sure that one sweats at a normal rate, enough to maintain the body temperature. However, there are cases in which this system gets revved up, causing sweating to occur at a very high level and at inappropriate times, regardless of the surrounding temperature. This medical condition is known as hyperhidrosis.
Hyperhidrosis can either be primary or secondary. The former is sometimes referred to as idiopathic hyperhidrosis since it occurs due to an unknown cause. It is more frequent than the latter and is focalized commonly in the hands, feet, armpits and face. This form of hyperhidrosis may begin as early as childhood and might even prolong for the rest of one's life. On the other hand, secondary hyperhidrosis affects the entire body. Excessive sweating of this kind is mostly caused by other medical conditions such as hyperthyroidism and obesity.C:\Users\Dell\Desktop\Problem_Areas_Sweating.jpg
Figure 1: Common problem areas in hyperhidrosisHyperhidrosis affects people of all ages, irrespective of genders. However, this condition is more prevalent in hot humid climates, affecting some races more than the others, particularly Middle Eastern Jews, Japanese and Taiwanese. It is also known to date that hyperhidrosis is experienced by approximately 3% of the world population.
Excessive sweating might not be considered as a serious or life-threatening condition. Nevertheless, the discomfort and complication arising from hyperhidrosis might heavily interfere with one's normal daily activities, debilitating the person's quality of life.
"My pencil used to slip out of my hands during class and my paper would stick to the side of my arm. When kids found out, they tried to make me do high-fives so they could see how sweaty I was and make fun of me. I dreaded school."
(Jerome, a hyperhidrosis sufferer)
A POSSIBLE SOLUTION - ENDOSCOPIC THORACIC SYMPATHECTOMY (ETS)
Out of the few treatments available, endoscopic thoracic sympathectomy (ETS) is found to be the most effective in addressing hyperhidrosis, particularly in severe cases affecting the face and palms. Minimally invasive, ETS generally works by removing completely or 'deactivating' by clamping the nerves that are responsible for triggering the sweat glands.
How ETS is conducted:
General anaesthesia is given before surgery.
Two small incisions are made on each side of the body just under the armpit.
A low amount of carbon dioxide gas is insufflated into the chest cavity. This if done to gently move the lungs aside
The sympathetic ganglion chain is located and then further exposed with the help of an endoscope.
Respective nerves are either clamped using titanium clamps or completely removed via cutting or cauterization.
For palmar and axillary sweating, the 3rd and 4th ganglia (T3-T4) are clamped / cut.
For facial sweating and blushing, the 2nd ganglion (T2) is clamped / cut.
Kuntz nerves are also identified and removed to prevent the recurrence of hyperhidrosis.
Once the operation is completed, the carbon dioxide gas is removed and the incisions are closed via an absorbable suture.
Figure 2: The locations of the sympathetic gangliaC:\Users\Dell\Desktop\How ETS is done.png
The effect of ETS is often immediate, meaning that patients are likely to awake with the affected areas dry and warm - showing that hyperhidrosis have been cured. The patient can later resume work within 48 hours and full physical activities only after one or two weeks.
The effectiveness of ETS in treating hyperhidrosis depends on the part of the body affected. Success rate is shown to be the highest among patients with palmar hyperhidrosis at 99.9%.
Type of problem
Success rate (%)
Scalp and facial sweating
Facial blushing and facial hyperpyrexia
85 - 95
75 - 90
Table 1: Success rate of ETS on hyperhidrosis at different parts of the body
A study was made in Japan to investigate how much ETS has affected the patients' quality of life. In this study, 40 patients with palmar hyperhidrosis (16 males and 26 females) who underwent ETS were followed up for about six months. Patients were given questionnaires prior to procedure and then again at 1, 3 and 6 months following operation. Results showed that no patients regretted undergoing ETS, though level of satisfaction changes with time.
Table 1: Success rate of ETS on hyperhidrosis at different parts of the body
BENEFITS AND RISKS
ETS definitely has some upper hands in comparison to other treatments. ETS is a relatively safe surgery since it is minimally invasive. Only small incisions are made, each measuring no more than 1/12th inch. Consequently, patients undergoing this surgery are less likely to experience intercostal nerve and chest muscle trauma. In addition, patients would experience less pain after operation and are only left with minimal scarring. The recovery period is also quick. In fact, most patients are ready to continue with their daily lives within a couple of days of surgery. Another thing is that by clamping (instead of cauterizing the sympathetic chain), patients would have the option to reverse the procedure if anything unfavourable is to happen after surgery.
Nonetheless, ETS does come with its own sets of problems. Like any other surgeries, there are always risks of bleeding and infection. Even so, what might be the major drawbacks of such a treatment are the side effects that it brings. The most prominent would be compensatory sweating (CS), whereby hyperhidrosis is transferred to the trunk, groin or lower extremities. This happens when residual trunctal sweat glands increase in activity to make up for the percentage of the total gland function lost after surgery. It is discovered that rates of mild CS varies from 14% to 90% among patients in different studies. While some may find this tolerable, severe CS (rates reported to vary from 1.2% to 30.9%) may have resulted in regrets among patients. Gustatory sweating (GS), facial sweating that occurs when eating certain foods such as spicy ones has also been reported to occur, though less common than CS.
Table 3: Rate of compensatory sweating (total and severe) and gustatory sweating in literature
Hyperhidrosis may be looked upon as trivial to some but it is in fact a serious condition. Those afflicted do not only experience physiological effects (cold and clammy hands, dehydration and skin maceration), but are also prone to mental and emotional breakdown. Excessive sweating makes even the simplest of routine activity a chore - even having a secure grasp on a pencil is never easy. Some if not most hyperhidrosis sufferers tend to be withdrawn, avoiding situations which require physical contact such as giving handshakes. This would definitely be physiologically debilitating, especially to children.
"It does not kill people, but it can really impact their ability to get along in the world." (Dee Anna Glaser, dermatologist, president of International Hyperhidrosis Society)
However, with ETS available, excessive sweating can be cured. Consequently, those previously suffering from hyperhidrosis can ever regain and boost their confidence especially in social terms. With this condition treated, patients would most likely experience an improvement in their quality of life. One would no more resort to wearing black clothes every single day nor put hands inside the pocket just to avoid embarrassment.
ETS is a quite expensive procedure. One would need to spend around US$3,000 - US$7,500 to undergo the surgery, depending on the surgeon's experience and the surgical procedure chosen. Many cannot afford such a treatment, especially those with low wages. In Malaysia, the cost for ETS may reach up to RM 8,000. This is not considered affordable for most Malaysians, whose general income averages at RM 3,000 to RM 3,500 per month. Most of those afflicted with hyperhidrosis would either spend on the less effective alternatives or just live with the condition.
The government should in fact subsidize ETS so that more people, particularly the underprivileged could get proper hyperhidrosis treatment without carrying much economic burden. Besides providing aid to the needy, this is a great step in highlighting the seriousness of hyperhidrosis itself.
Iontophoresis is a non-invasive technique by which medicine or chemical compounds are transferred transdermally via the use of a small electric charge. In the treatment of hyperhidrosis, patients would need to immerse the affected area (palms/feet) in an electrolyte solution before applying a low intensity electric current (15-18 mA) supplied by a DC generator. This process is done within a short period of time (20-40 minutes) and may need to be repeated every day for five to ten days until sweating is significantly reduced. Depending on the individual, patients would later switch to a maintenance schedule where iontophoresis could be done from once per week to once per month. Not much is understood on how iontophoresis really works but it is thought that the mineral particles in the electrolyte serve to thicken the skin's outer layer so that sweat is blocked from coming out and hence reduce sweating.
Figure 3: An iontophoresis machineThis method might work wonders for those having mild palmar and planar hyperhidrosis but is relatively inefficient for those with severe cases. Plus, this treatment is not recommended to people with axillary hyperhidrosis since the skin around the armpit may become irritated by the process, not forgetting the fact that performing iontophoresis on the underarms is pretty difficult. Since this treatment is not permanent, patients should expect a prolonged use of the machine which costs around US$700.C:\Users\Dell\Desktop\iontophoresis_using.jpg
Botox (onabotulinumtoxinA) might be famous in the world of cosmetics, thanks to its ability in reducing wrinkles but it is also gaining popularity as a form of treatment to hyperhidrosis. Botox was officially approved by the US Food & Drug Administration (FDA) for the treatment of severe primary axillary hyperhidrosis on July 19th 2004. Since then, much research has been done to show how effective Botox can be in treating excessive sweating. In a clinical study involving 322 patients suffering serious axillary hyperhidrosis, 81% of the patients showed reduced sweating of more than 50% after receiving the injections. This lasted to nearly seven months for almost 50% of the patients. Apparently, Botox has the ability to temporarily block off chemicals in the nervous system which activate the sweat glands. With this chemicals cut off, sweating cease to occur.
As with other treatments, Botox injection only provides a temporary means of curbing hyperhidrosis. Patients will have to meet a specialist after every 7 months to get further injections. Treatment is also very costly and may reach up to US$1,500. Furthermore, Botox injection can be very painful to some especially when done on the sensitive parts of the palms and soles.C:\Users\Dell\Desktop\botox_injections.png
Figure 4: Botox injection around the axillary
The International Hyperhidrosis Society (IHS) is the only independent, non-profit, global organization which aims to provide help to the hyperhidrosis community through up-to-date information. Its website, www.sweathelp.org is highly trustworthy and I believe that the facts stated on the site are all true and valid since it is managed with the help of the IHS's Board of Directors which comprises of specialists leading in hyperhidrosis research. Its president cum founder, Dr. Dee Anna Glaser is in fact the current Vice Chairman of the Department of Dermatology in Saint Louis University School of Medicine. Besides, this website contains many review articles and points out numerous recent researches.
Most of the information on hyperhidrosis (page 2) and ETS was taken from the book Pediatric Thoracic Surgery. I find this source very reliable since it is written by specialists in their respective fields. It should also be noted that this book is recently published in 2009. It should contain the latest and most up-to-date information regarding hyperhidrosis and its treatments.