HYPERHIDROSIS - HYPERHIDROSIS HYPERHIDROSIS A Comprehensive Review Dina Hamadi R.N B.S.N Alverno College Master’s of Science in Nursing

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Unformatted text preview: HYPERHIDROSIS: HYPERHIDROSIS: A Comprehensive Review Dina Hamadi, R.N., B.S.N. Alverno College: Master’s of Science in Nursing Master’s Navigating the Tutorial Navigating will take you to the next slide will will take you to the previous slide will will take you to the home page will Objectives Objectives Understand the pathophysiology of Understand sweating sweating Identify diagnostic criteria for Identify Hypherhidrosis Hypherhidrosis Identify treatment options for the Identify Hyperhidrosis patient Hyperhidrosis Choose the Topic! Choose Sweat glands What makes me sweat? What is Hyperhidrosis? Treatment Options Sweat Glands Sweat The human body has 2-5 million sweat The glands glands Two main types: ECCRINE Click on the different sweat gland types to learn more! Source: www.sweathelp.org Click the “Home” button after viewing both types APOCRINE Eccrine Sweat Glands Eccrine Approximately 3 million Approximately eccrine sweat glands eccrine Secrete a clear, odorless Secrete fluid fluid Aid in regulating body Aid temperature temperature Areas of concentration: Facial, plantar, and axillae Source: www.sweathelp.org CLICK HERE Apocrine Sweat Glands Apocrine Inactive until puberty Produce thick fluid Secretions come in Secretions contact with bacteria on the skin and produce characteristic “body odor” odor” Found in axillary and Found genital areas genital Source: www.sweathelp.org CLICK HERE Sweating The hypothalamus serves as the thermoregulatory center thermoregulatory It controls both blood flow and sweat output to the skin’s surface output Source: www.sweathelp.org Sweating Sweating The hypothalamus can be triggered by: The EXERCISE STRESS TEMPERATURE CHANGE HORMONES Source: www.sweathelp.org Sweating Sweating Once triggered, the hypothalamus sends messages down the spinal cord via neurotransmitters. Source: www.sweathelp.org Sweating Sweating The neurostransmitters travel down the The spine via ganglion or sympathetic nerves ganglion These ganglion travel to nerves, which These reach the skin’s surface reach Source: www.sweathelp.org Photo used with permission: The Whiteley Clinic,2007 Neurotransmitters Neurotransmitters Neurotransmitters act as “vehicles,” transmitting information from the hypothalamus to the skin’s surface. Photo used with permission: The Whiteley Clinic, 2007 Neurotransmitters Neurotransmitters The neurotransmitters can “exit” at various The places along the spinal cord. places The “exit” determines the location of skin The innervation. innervation. Spinal Cord Innervations Spinal T2-T4 innervate the skin of the face T4-T12 innervate the skin of the trunk Source: www.sweathelp.org T2 – T8 innervate the skin of the upper limbs T10-T12 innervate the skin of the lower limbs Neurotransmitters Neurotransmitters Catecholamines Acetylcholine innervate innervates Eccrine Sweat Glands Apocrine Sweat Glands Source: www.sweathelp.org Sweating Sweating Once innervated, the apocrine and eccrine Once glands will produce …. glands Source: www.sweathelp.org SWEAT! SWEAT! Click on the picture to take the “Sweating Quiz” Click on the “Home” button to return to the topic choices Question 1 Question What serves as the body’s thermoregulatory What center? center? The hypothalamus b. The adrenal cortex c. The frontal lobe a. CONGRATULATIONS ! C ONGRATULATIONS The hypothalamus regulates sweat output The hypothalamus and blood flow to the skin’s surface! and Take me to question 2! S ORRY….TRY AGAIN! Wha t re gula te s blood flow a nd s we a t output Wha to the s kin’s s urfa ce ? to a . The hypotha la mus b. The a dre na l corte x c. The fronta l lobe Question 2 Question What neurotransmitter innervates eccrine What sweat glands? sweat Acetylcholine b. Catecholamine c. Glucose a. You’re Right!! You’re Take me to question 3! Try Again! Try Hint: Catecholamines innervate apocrine apocrine sweat glands! sweat Let me try question 2 again! Question 3 Question The hypothalamus can be triggered by all The these except: except a. Stress b. Exercise c. Obesity d. Temperature change CORRECT!! CORRECT!! You have successfully completed this section of the tutorial. Return home! Try Again! Try Return to question 3! Hyperhidrosis Hyperhidrosis Hyperhidrosis is a state of Hyperhidrosis excessive sweating of the axilla, palms, soles, or face that interferes with daily activities daily Haider & Solish, 2004 Photo used with permission: University of Miami Cosmetic Center, 2007 Two Types Two Primary or idiopathic or Secondary: Resulting from respiratory/heart failure, malignancy, drug/alcohol abuse, malignancy, hyperthyroidism, infection hyperthyroidism, Haider & Solish, 2004 Fun Facts Fun Diagnosed in 2.8% of the U.S. population 70% of those with symptoms do not 70% consult a physician consult Peaks in early adulthood Haider & Solish, 2004 Diagnostic Criteria: Diagnostic Primary Hyperhidrosis MUST HAVE 1. Focal, visible, excessive sweating 2. 6 months duration 3. No apparent cause TWO OR MORE: 1. Bilateral and symmetric sweating 2. Impairment of daily activities 3. At least one episode per week 4. Onset of less than 25 years 5. Positive family history Hornberger, 2004 What is Hyperhidrosis? What Involves the eccrine sweat glands, however: Involves however Sweat glands are NORMAL Sweat NORMAL No change in size No change in shape No change in number Haider & Solish, 2004 Cause Cause Exact cause is unknown Familial or genetic? Familial Excessive Sympathetic Activity? Click on the raindrops to learn more about this theory! Excessive Sympathetic Activity Excessive The eccrine sweat glands are excessively stimulated by acetylcholine Increased SWEAT production Hornberger, 2004 Excessive Sympathetic Activity Excessive Because the sweat glands are continuously Because stimulated, they are stuck in the position position Hornberger, 2004 QUIZ TIME! QUIZ Those diagnosed with hyperhidrosis have Those abnormal eccrine sweat glands. abnormal TRUE FALSE FALSE GOOD JOB! GOOD The sweat glands are normal, with no The variance in size, shape, or number! variance Take me to Question 2! SORRY! SORRY! Try again…. Click on the sad face to try again! Question 2 Question Hyperhidrosis involves which sweat gland Hyperhidrosis type? type? Apocrine Eccrine Oops! Oops! Take me back to the question! YES!! YES!! Hyperhidrosis involves the eccrine sweat Hyperhidrosis glands! glands! You have successfully completed this section of the tutorial. You may return Home! Treatment Options Treatment Rules to Follow: Different treatment for areas affected Always start with least invasive treatment Always option option Topical Treatment Options Treatment Click on the first treatment option to begin! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Topical Treatment Topical First line treatment Aluminum Chloride Hexahydrate antiperspirant of choice antiperspirant Most beneficial for axillary Most hyperhidrosis hyperhidrosis Can be used for plantar and palmar Hornberger, 2004 Photos used with permission: www.feelbest.com Topical Treatment: Topical How Does it Work? 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 Topical Treatment Topical Sweat production never Sweat ceases, the gland is simply plugged plugged Sweating will return as the Sweating skin undergoes regeneration or shedding regeneration Photo used with permission: Neurosurgical Medical Clinic, Inc Therefore…topical Therefore…topical treatment is NOT a cure! treatment Hornberger, 2004 Topical Treatment: Topical How to Use Best to apply before bedtime Allow to remain on skin for 6 – 8 hours Apply every 24 – 48 hours until sweating Apply diminishes diminishes Maintenance applications needed every 13 weeks Hornberger, 2004 Topical Treatment: Pros and Cons Pros n– No Hornberger, 2004 ive as inv Itch in g and at a bur ppl ica ning o tion f sk Tim site in & e-c ons um Tem in g & por ary reli ef Topical Treatment: Topical Effectiveness 88% effective for Axillary Hyperhidrosis 66.6% stop using due to the “CONS” Naumann, Hamm, & Lowe, 2002 QUICK REVIEW! QUICK Fill in the Blank! Topical Treatments work by ________ Topical sweat glands. sweat Destroying Plugging Melting That’s Right! That’s Topical Treatments PLUG the sweat gland Take me to the next treatment option! Sorry! Sorry! HINT: Sweat production never stops, the output is simply blocked! output Take me back to the question! Topical Treatment Options Treatment Click on the second treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Systemic Treatment Systemic Anticholinergics can be used in treating Anticholinergics hyperhidrosis hyperhidrosis Most effective for cranio-facial Most hyerhidrosis hyerhidrosis Robinul – drug of choice Haider & Solish, 2004 How Does it Work? How Anticholinergic Blocks Acetylcholine transmission Eccrine sweat glands no longer stimulated Sweat production ceases! Haider & Solish, 2004 Anticholinergics Anticholinergics Long term therapy is required Major side effects: Dry mouth Dry eyes Constipation Constipation Blurred vision Blurred Difficulty with urination Thomas, Brown, & Vafaie, 2004 Anticholinergics Anticholinergics Limited use in treating Limited hyperhidrosis hyperhidrosis Only 21% effective 69.7% stop using due 69.7% to side effects to Hamm, Naumann, & Kowalski, 2006 Review Review Anticholinergics block transmission of Anticholinergics ? Catecholamines b. Epinephrine c. Acetylcholine a. Yes!! Yes!! Acetylcholine transmission is blocked! Take me to the next treatment option! Sorry! Sorry! Click on the picture to try again! Topical Treatment Options Treatment Click on the third treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Iontophoresis Iontophoresis Used for palmar and Used plantar hyperhidrosis plantar Passage of direct Passage electrical current onto skin’s surface skin’s Device can be Device purchased for home use purchased Thomas, Brown, & Vafaie, 200 4 Photo used with permission: Beast Psoriasis, 2006 Iontophoresis Iontophoresis Photo used with permission: Beat Psoriasis, 2006 Sit with hands or feet in Sit shallow tray of water shallow Allow 15 – 20 milli-amps of Allow electrical current to pass through water through Use for 10 days, 30 Use minutes each day minutes Maintenance therapy Maintenance needed needed Thomas, Brown, & Vafaie, 2004 Iontophoresis: Iontophoresis: Mechanism of Action + WATER www.sweathelp.org = ELECTRICTY Thickening of skin And Blocked sweat flow Iontophoresis Iontophoresis Side effects: Skin irritation Skin burns Vesicle formation Photo used with permission: Beat Psoriasis, 2006 Time consuming treatment 80% effective for palmar and/or plantar 80% hyperidrosis hyperidrosis Thomas, Brown, and Vafaie, 2004 Iontophoresis Iontophoresis Contraindicated in those: 1. Who are pregnant 2. Have pacemakers 3. Have metal implants 4. Have cardiac conditions 5. Have epilepsy Question…. Question…. Iontophoresis is NOT used in treating which Iontophoresis type of hyperhidrosis? type Palmar b. Axillary Axillary c. Plantar c. a. Yes! Yes! Iontophoresis can be Iontophoresis used in treating Palmar and/or Plantar Palmar Plantar hyperhidrosis hyperhidrosis Take me to the next treatment option Try Again! HINT: Look at these pictures…. HINT: Click on either picture to Try again! Photos used with permission: Beat Psoriasis, 2006 Topical Treatment Options Treatment Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Botox Botox Botox injections can be used to treat Botox axillary, palmar, and plantar hyperhidrosis axillary, Analgesic applied prior to injection Nerve block applied to ulnar or radial Nerve nerve prior to palmar injection Haider & Solish, 2004 Botox Botox Starch Iodine test Starch done prior to injection done Delineates areas of Delineates excess sweating with black-purple discoloration of the skin skin Haider & Solish, 2004 Photo used with permission: Eisenach, Atkinson, & Fealey, 2005 Botox Botox Botox blocks the release of acetylcholine at the site of the neuromuscular junction. Sweat glands are not stimulated, and sweat production ceases Photo used with permission: Whiteley Clinic, 2007 Site of blockage Haider & Solish, 2004 Botox Botox Pros: Lasts 6-7 months 90% effective Cons: Very painful to the Very palms and soles of feet feet Expensive: $1400$1600 per treatment Thomas, Brown, & Vafaie, 2004 Quick Review Quick A Starch-Iodine test is done prior to botox Starch-Iodine injection. injection. True True False False Correct! Correct! This test highlights areas of excessive This sweating! sweating! Take me to the next treatment option Try Again! Try Hint: The test gives a “map,” highlighting Hint: areas of excessive sweating areas Click on the picture to try again! Click Topical Treatment Options Treatment Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Local Excision Local Used only for axillary Used hyperhidrosis hyperhidrosis Starch Iodine test done prior to Starch excision excision Performed under local Performed anesthesia Vasoconstrictor applied to axillary region axillary Small incisions made Photo used with permission: Gasparri, 2006 Eisenach, Atkinson, Foley, 2005 Local Excision Local Eccrine sweat glands removed through: Liposuction – suctioned out Curettage – scraped out Excision – cut out Incisions sutured Pain and bruising to excision site Photo used with permission: Gasparri, 2006 Eisenach, Atkinson, & Fealey, 2005 Local Excision Local Starch Iodine tests done post excision Starch show 80% - 90% decrease in sweating show Has a potential for scarring Eisenach, Atkinson, & Fealey, 2005 Review! Review! Local Excision is used for what type of Local hyperhidrosis? hyperhidrosis? Plantar b. Palmar c. Axillary a. Correct! Correct! Local Excision is used for axillary Local hyperhidrosis! hyperhidrosis! Take me to the next treatment option! Try Again! Try Click on the picture to try again! Topical Treatment Options Treatment Click on the fourth treatment option! Systemic Iontophoresis Botox Local Excision Thorascopic Sympathectomy Endoscopic Thoracic Sympathectomy (ETS) Sympathectomy Last treatment option PERMANENT PERMANENT Surgery performed under general anesthesia anesthesia Haider & Solish, 2004 ETS ETS Goal of surgery is to excise or ablate the Goal ganglion that innervate the sweat glands ganglion Performed most frequently for palmar Performed hyperhidrosis hyperhidrosis Performed through thorascope or video thorascope Minimally invasive Han, Oren, & Gottfried, 2002 Photo used with permission: Neurosurgical Medical Clinic, Inc ETS ETS Small incision made laterally under each Small axilla axilla Incision made through intercostal space Surgery can be performed on outpatient Surgery basis However, some patients remain in hospital However, for one night for Han, Oren, & Gottfried, 2002 ETS ETS Ganglion located along Ganglion the sympathetic chain Ganglion formed below each rib each Ganglion can be divided Ganglion = sympathicotomy sympathicotomy Ganglion can be Ganglion removed = sympathectomy sympathectomy www.sweathelp.org Photo used with permission: Neurosurgical Medical Clinic, Inc ETS ETS Ganglion at T2 and T3 = palmar Ganglion hyperhidrosis hyperhidrosis Ganglion at T3 and T4 = axillary Ganglion hyperhidrosis hyperhidrosis Ganglion at L2-L4 = plantar hyperhidrosis www.sweathelp.org Photos used with permission: Neurosurgical Medical Clinic, Inc ETS ETS Cannot surgically excise or ablate L2-L4 Cannot for plantar hyperhidrosis due to sexual side effects side 95% success rate in curing palmar 95% hyperhidrosis hyperhidrosis Success rates slightly lower for axillary Success hyperhidrosis hyperhidrosis Eisenach, Atkinson, & Fealey, 2005 ETS ETS Plantar hyperhidrosis resolves in 50% Plantar 75% of cases when T2 and T3 are excised, though L2-L4 ganglion are never surgically treated surgically Mechanism is unknown! Eisenach, Atkinson & Fealey, 2005 ETS: Side Effects ETS: Surgical complications: Hemo-pneumothorax requiring chest tube Hemo-pneumothorax placement – 1% placement Atelectasis Intercostal neuralgia – 1% Horner’s Syndrome – 1% Compensatory Sweating – 60% Eisenach, Atkinson, & Fealey, 2005 Horner’s Syndrome Horner’s Stellate ganglion – fusion of C8 and T1 Innervates the face If Stellate ganglion is damaged, Horner’s If Syndrome will occur Syndrome May be mistaken for T2 and T3 May May receive electrical current from cautery of T2 and T3 T2 www.sweathelp.org Horner’s Syndrome Horner’s Signs and Symptoms Unilateral upper eyelid ptosis Pupil constriction Facial anhidrosis www.sweathelp.org Compensatory Sweating Compensatory Most frequent Most complication – 60% of post-op patients post-op Severe sweating noted Severe to abdomen, chest, back, and thighs and More severe for those More who live in a hot climate who www.sweathelp.org Photo used with permission: ETS Discussion Forum and Reversals, 2005 Compensatory Sweating Compensatory Mechanism poorly understood Theory states: Photo used with permission: ETS Discussion Forum and Reversals, 200 After excision of T2 and T3, 40% of After body’s sweat function is lost body’s Body tries to compensate for this loss Body Andrews & Rennie, 1997 Compensatory Sweating Compensatory Most patients feel compensatory Most sweating is a minor draw-back to surgery surgery Sweating to abdomen/trunk = Sweating less interference with daily activities activities Able to write/handle objects Gossot, Galetta, & Pascal, 2003 Photo used with permission: ETS Discussion Forum and Reversals, 2005 Let’s Review Let’s ETS is performed most often for what type ETS of hyperhidrosis: of Axillary b. Palmar c. Plantar a. CORRECT! CORRECT! ETS is performed for palmar hyperhidrosis! Take me to the next question! TRY AGAIN! TRY Click on the picture to try again! Question 2 Question What is the most significant side effect of What ETS? ETS? Hemo-pneumothorax b. Horner’s Syndrome c. Compensatory Sweating a. That’s Right! That’s Compensatory Sweating can occur in 60% Compensatory of post-op patients! of Take me to the next activity! Sorry! Sorry! Horner’s Syndrome and Hemopneumothorax only occur in 1% of the pneumothorax cases! cases! Click on the face to try again! Click Treatment Option Review Treatment AXILLARY Hyperhidrosis PALMOPLANTAR Topical Treatment Botox Iontophoresis Local Excision Iontophoresis Botox ETS Hornberger, 2004 Treatment Option Review Treatment Systemic – blocks acetylcholine Photo used with permission: The Whiteley Clinic, 2007 CONGRATUALTIONS!! CONGRATUALTIONS!! YOU HAVE SUCCESSFULLY YOU COMPLETED THIS TUTORIAL!! COMPLETED References References Andrews, B. T. & Renni, J. A. (1997). Predicting changes in the distribution of Andrews, sweating following thorascopic sympathectomy. The British Journal of Surger, 84(12), 1702-1704. 84 Beat Psoriasis. (2006). What is hyperhidrosis or excessive sweating? Retrieved Beat What March 22, 2007, from www.beatpsoriasis.com. March Canada’s Largest Online Health and Beauty Aids. (n.d.). Retrieved April 12, Canada’s 2007, from www.feelbest.com. www.feelbest.com Eisenach, J., Atkinson, J., & Fealey, R. (2005). Hyperhidrosis: Evolving Eisenach, therapies for a well-established phenomenon. Mayo Clinic Proceedings, therapies Mayo 80(5), 657-666. 80 ETS Discussion Forum and Reversals. (2005). Compensatory sweating after ETS ets. Retrieved March 22, 2007, from ets. http://p069.ezboard.com/fetsandreversalsfrm37.showMessage?topicID=1. http://p069.ezboard.com/fetsandreversalsfrm37.showMessage?topicID=1 Gasparri, M. (2006). Photography, Medical College of Wisconsin. Gossot, D., Galetta, D., & Pascal, A. (2003). Long-term results of endoscopic Gossot, thoracic sympathectomy for upper limb hyperhidrosis. The Society of Thoracic Surgeons, 75, 1075-1079. 75, Haider, A. & Solish, N. (2004). Hyperhidrosis: An approach to diagnosis and Haider, management. Dermatology Nursing, 16(6), 515-523. Dermatology References References Hamm, H., Naumann, M., & Kowalski, J. (2006). Primary focal hyperhidrosis: Disease Hamm, characteristics and functional impairment. Dermatology, 212. 343-353. Dermatology, 343-353. Hornberger, J. (2004). Recognition, diagnosis, and treatment of primary focal hyperhidrosis. Journal of the American Academy of Dermatology, 51(2), 274-286. 51 International Hyperhidrosis Society. (2007). About hyperhidrosis: Physiology of normal International sweating. Retrieved March 7, 2007, from http://www.sweathelp.org. sweating Retrieved http:// Naumann, M. K., Hamm, H., & Lowe, J. (2002). Effects of botulinim toxin type A on Naumann, quality of life measures in patients with excessive axillary sweating: A randomized controlled trial. British Journal of Dermatology, 147, 1218-1226. British Neurosurgical Medical Clinic, Inc. (n.d.). Neurosurgical Diseases: Hyperhidrosis. Neurosurgical Retrieved March 23, 2007, from www.sdRetrieved neurosurgeon.com/diseases/hyperhidrosis.html. Thomas, I., Brown, J. & Vafaie, J. (2004). Palmoplantar hyperhidrosis: A therapeutic Thomas, challenge. American Family Physician, 69(5,) 1117-1120. 69 Unatrributed Clip Art: Microsoft Office, 2006. Unatrributed University of Miami Cosmetic Center. (2007). Botox for Hyperhidrosis. Retrieved April 10, Botox Retrieved 2007, from www.derm.net/bo_hyperhidrosis.shtml. www.derm.net/bo_hyperhidrosis.shtml Whiteley Clinic. (2007). The latest treatment in excessive sweating. Retrieved April 2, Whiteley The 2007, from www.sweating.co.uk. www.sweating.co.uk ...
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