1. HYPERHIDROSIS:
A Comprehensive Review
Dr Rida Akmal
PGR Dermatology Department
DHQ Hospital Faisalabad

2. Objectives
To understand the pathophysiology of
sweating
Identify diagnostic criteria for
Hypherhidrosis
Identify treatment options for the
Hyperhidrosis patient
10/5/2012
Dr. Rida Akmal 2
DHQ Hospital Fsd

3. Sweat glands
What makes sweat?
What is Hyperhidrosis?
Treatment Options
10/5/2012
Dr. Rida Akmal 3
DHQ Hospital Fsd

4. Sweat Glands
The human body has 2-5 million sweat
glands
Two main types:
ECCRINE
APOCRINE
10/5/2012
Dr. Rida Akmal 4
DHQ Hospital Fsd

5. Eccrine Sweat Glands
Approximately 3 million
eccrine sweat glands
Secrete a clear, odorless
fluid
Help in regulating body
temperature
Areas of concentration:
Facial, plantar, and axillae
10/5/2012
Dr. Rida Akmal 5
DHQ Hospital Fsd

6. Apocrine Sweat Glands
Inactive until puberty
Produce thick fluid
Secretions come in
contact with bacteria on
the skin and produce
characteristic “body
odor”
Found in axillary and
genital areas
10/5/2012
Dr. Rida Akmal 6
DHQ Hospital Fsd

7. Sweating
The hypothalamus serves as the
thermoregulatory center
It controls both blood flow and sweat
output to the skin’s surface
10/5/2012
Dr. Rida Akmal 7
DHQ Hospital Fsd

8. Sweating
The hypothalamus can be triggered by:
EXERCISE
STRESS
TEMPERATURE CHANGE
HORMONES
10/5/2012
Dr. Rida Akmal 8
DHQ Hospital Fsd

9. Sweating
Once triggered,
the hypothalamus sends messages down the
spinal cord
via nerve signals.
10/5/2012
Dr. Rida Akmal 9
DHQ Hospital Fsd

10. Sweating
The neurostransmitters travel down the
spine via ganglion or sympathetic nerves
These ganglion travel to nerves, which
reach the skin’s surfacec
10/5/2012
Dr. Rida Akmal 10
DHQ Hospital Fsd

11. Neurotransmitters
Neurotransmitters act as “vehicles,” transmitting
information from the hypothalamus to the skin’s surface.
Photo used with permission:
10/5/2012
Dr. Rida Akmal 11
The Whiteley Clinic, 2007 DHQ Hospital Fsd

12. Neurotransmitters
The neurotransmitters can “exit” at various
places along the spinal cord.
10/5/2012
Dr. Rida Akmal 12
DHQ Hospital Fsd

13. Spinal Cord Innervations
T2-T4 innervate T2 – T8 innervate the
the skin of the face skin of the upper limbs
T4-T12 innervate the
skin of the trunk T10-T12 innervate the skin
of the lower limbs
10/5/2012
Dr. Rida Akmal 13
DHQ Hospital Fsd

14. Neurotransmitters
Acetylcholine Catecholamines
innervates innervate
Eccrine Sweat Apocrine Sweat
Glands Glands
10/5/2012
Dr. Rida Akmal 14
DHQ Hospital Fsd

15. Sweating
Once innervated, the apocrine and eccrine
glands will produce ….
SWEAT!
10/5/2012
Dr. Rida Akmal 15
DHQ Hospital Fsd

16. Question 1
What serves as the body’s thermoregulatory
center?
a. The hypothalamus
b. The adrenal cortex
c. The frontal lobe
10/5/2012
Dr. Rida Akmal 16
DHQ Hospital Fsd

17. CONGRATULATIONS!
The hypothalamus regulates sweat output
and blood flow to the skin’s surface!
10/5/2012
Dr. Rida Akmal 17
DHQ Hospital Fsd

18. SORRY….TRY AGAIN!
What regulates blood flow and sweat output
to the skin’s surface?
a. The hypothalamus
b. The adrenal cortex
c. The frontal lobe
10/5/2012
Dr. Rida Akmal 18
DHQ Hospital Fsd

19. Question 2
What neurotransmitter innervates eccrine
sweat glands?
a. Acetylcholine
b. Catecholamine
c. Glucose
10/5/2012
Dr. Rida Akmal 19
DHQ Hospital Fsd

20. You’re Right!!
10/5/2012
Dr. Rida Akmal 20
DHQ Hospital Fsd

21. Try Again!
Hint: Catecholamines innervate apocrine
sweat glands!
10/5/2012
Dr. Rida Akmal 21
DHQ Hospital Fsd

22. Question 3
The hypothalamus can be triggered by all
these except:
a. Stress
b. Exercise
c. Obesity
d. Temperature change
10/5/2012
Dr. Rida Akmal 22
DHQ Hospital Fsd

23. CORRECT!!
10/5/2012
Dr. Rida Akmal 23
DHQ Hospital Fsd

24. Try Again!
10/5/2012
Dr. Rida Akmal 24
DHQ Hospital Fsd

25. Sweating Nomeculture
Areas: Focal, regional, generalized
Symmetry: Symmetric or asymmetric
Classification: Primary vs. secondary
Type of sweating: Anhidrosis, euhydrosis,
hyperhidrosis
10/5/2012
Dr. Rida Akmal 25
DHQ Hospital Fsd

26. Hyperhidrosis
Hyperhidrosis is a state of
excessive sweating of the
axilla, palms, soles, or
face that interferes with
daily activities
10/5/2012
Dr. Rida Akmal 26
DHQ Hospital Fsd

27. Hyperhydrosis
Qualitative definition is
subjective
Quantitative definition
for research is
production of more than
100ml of sweat in 1
axilla over 5 minutes
10/5/2012
Dr. Rida Akmal 27
DHQ Hospital Fsd

28. 10/5/2012
Dr. Rida Akmal 28
DHQ Hospital Fsd

29. Causes of Generalized Hyperhidrosis
Usually secondary in nature
Drugs, toxins, substance abuse
Cardiovascular disorders
Respiratory failure
Infections
29
Dr. Rida Akmal DHQ Hospital Fsd

30. Malignancies
Hodgkin’s, myleoproliferative disorders,
cancers with increased catabolism
Endocrine/metabolic disorders
Thyrotoxicosis, pheochromocytoma,
acromegaly, carcinoid tumor,
hypoglycemia, menopause
rarely Idiopathic
10/5/2012 30

31. Causes of Localized Hyperhidrosis
Usually Idiopathic / Primary
Social anxiety disorder
Eccrine nevus
Gustatory sweating
Frey syndrome
Impaired evaporation
Stump hyperhidrosis after amputation
31
Dr. Rida Akmal DHQ Hospital Fsd

32. Two Types
 Primary or idiopathic
 Secondary:
Resulting from respiratory/heart failure,
malignancy, drug/alcohol abuse,
hyperthyroidism, infection
10/5/2012
Dr. Rida Akmal 32
DHQ Hospital Fsd

33. Fun Facts
70% of those with symptoms do not
consult a physician
Peaks in early adulthood
10/5/2012
Dr. Rida Akmal 33
DHQ Hospital Fsd

34. Diagnostic Criteria:
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
10/5/2012
Dr. Rida Akmal 34
DHQ Hospital Fsd

35. What is Hyperhidrosis?
Involves the eccrine sweat glands, however:
Sweat glands are NORMAL
No change in size
No change in shape
No change in number
10/5/2012
Dr. Rida Akmal 35
DHQ Hospital Fsd

36. Cause
Exact cause is unknown
Familial or genetic?
Excessive Sympathetic Activity?
10/5/2012
Dr. Rida Akmal 36
DHQ Hospital Fsd

37. Excessive Sympathetic Activity
The eccrine sweat glands
are excessively
stimulated by acetylcholine
Increased SWEAT production
10/5/2012
Dr. Rida Akmal 37
DHQ Hospital Fsd

38. Excessive Sympathetic Activity
Because the sweat glands are continuously
stimulated, they are stuck in the
position
10/5/2012
Dr. Rida Akmal 38
DHQ Hospital Fsd

39. QUIZ TIME!
Those diagnosed with hyperhidrosis have
abnormal eccrine sweat glands.
TRUE
FALSE
10/5/2012
Dr. Rida Akmal 39
DHQ Hospital Fsd

40. GOOD JOB!
The sweat glands are normal, with no
variance in size, shape, or number!
10/5/2012
Dr. Rida Akmal 40
DHQ Hospital Fsd

41. SORRY!
Try again….
10/5/2012
Dr. Rida Akmal 41
DHQ Hospital Fsd

42. Question 2
Hyperhidrosis involves which sweat gland
type?
Apocrine
Eccrine
10/5/2012
Dr. Rida Akmal 42
DHQ Hospital Fsd

43. Oops!
10/5/2012
Dr. Rida Akmal 43
DHQ Hospital Fsd

44. YES!!
Hyperhidrosis involves the eccrine sweat
glands!
10/5/2012
Dr. Rida Akmal 44
DHQ Hospital Fsd

45. 10/5/2012
Dr. Rida Akmal 45
DHQ Hospital Fsd

46. Treatment Options
Rules to Follow:
Different treatment for areas affected
Always start with least invasive treatment
option
10/5/2012
Dr. Rida Akmal 46
DHQ Hospital Fsd

47. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 47
DHQ Hospital Fsd

48. Topical Treatment
First line treatment
Aluminum Chloride Hexahydrate
antiperspirant of choice Photos used with permission:
www.feelbest.com
Most beneficial for axillary
hyperhidrosis
Can be used for plantar and palmar
10/5/2012
Dr. Rida Akmal 48
DHQ Hospital Fsd

49. Topical Treatment:
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.
10/5/2012
Dr. Rida Akmal 49
DHQ Hospital Fsd

50. Topical Treatment
Sweat 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!
Hornberger, 2004
10/5/2012
Dr. Rida Akmal 50
DHQ Hospital Fsd

51. Topical Treatment:
How to Use
Best to apply before bedtime
Allow to remain on skin for 6 – 8 hours
Apply every 24 – 48 hours until sweating
diminishes
Maintenance applications needed every 1-
3 weeks
10/5/2012
Dr. Rida Akmal 51
DHQ Hospital Fsd

52. Topical Treatment:
Pros and Cons
10/5/2012
Dr. Rida Akmal 52
DHQ Hospital Fsd

53. Topical Treatment:
Effectiveness
88% effective for
Axillary Hyperhidrosis
66.6% stop using due
to the “CONS”
10/5/2012
Dr. Rida Akmal 53
DHQ Hospital Fsd

54. QUICK REVIEW!
Fill in the Blank!
Topical Treatments work by ________
sweat glands.
Destroying
Plugging
Melting
10/5/2012
Dr. Rida Akmal 54
DHQ Hospital Fsd

55. That’s Right!
Topical Treatments PLUG the sweat gland
10/5/2012
Dr. Rida Akmal 55
DHQ Hospital Fsd

56. Sorry!
HINT: Sweat production never stops, the
output is simply blocked!
10/5/2012
Dr. Rida Akmal 56
DHQ Hospital Fsd

57. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 57
DHQ Hospital Fsd

58. Systemic Treatment
Anticholinergics can be used in treating
hyperhidrosis
Most effective for cranio-facial hyerhidrosis
Robinul – drug of choice
10/5/2012
Dr. Rida Akmal 58
DHQ Hospital Fsd

59. How Does it Work?
Anticholinergic
Blocks Acetylcholine transmission
Eccrine sweat glands no longer stimulated
Sweat production ceases!
10/5/2012
Dr. Rida Akmal 59
DHQ Hospital Fsd

60. Anticholinergics
Long term therapy is required
Major side effects:
Dry mouth
Dry eyes
Constipation
Blurred vision
Difficulty with urination
10/5/2012
Dr. Rida Akmal 60
DHQ Hospital Fsd

61. Anticholinergics
Limited use in treating
hyperhidrosis
Only 21% effective
69.7% stop using due
to side effects
10/5/2012
Dr. Rida Akmal 61
DHQ Hospital Fsd

62. Review
Anticholinergics block transmission of
?
a. Catecholamines
b. Epinephrine
c. Acetylcholine
10/5/2012
Dr. Rida Akmal 62
DHQ Hospital Fsd

63. Yes!!
Acetylcholine transmission is blocked!
10/5/2012
Dr. Rida Akmal 63
DHQ Hospital Fsd

64. Sorry!
10/5/2012
Dr. Rida Akmal 64
DHQ Hospital Fsd

65. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 65
DHQ Hospital Fsd

66. Iontophoresis
 Used for palmar and
plantar hyperhidrosis
 Passage of direct
electrical current onto
skin’s surface
 Device can be purchased
for home use
10/5/2012
Dr. Rida Akmal 66
DHQ Hospital Fsd

67. Iontophoresis
Sit with hands or feet in
shallow tray of water
Allow 15 – 20 milli-amps of
electrical current to pass
through water
Use for 10 days, 30
minutes each day
Maintenance therapy
needed
Thomas, Brown, & Vafaie, 2004
10/5/2012
Dr. Rida Akmal 67
DHQ Hospital Fsd

68. Iontophoresis:
Mechanism of Action
+ = Thickening of skin
And
Blocked sweat flow
WATER ELECTRICTY
10/5/2012
Dr. Rida Akmal 68
DHQ Hospital Fsd

69. Iontophoresis
Side effects:
Skin irritation
Skin burns
Vesicle formation
Time consuming treatment
80% effective for palmar and/or plantar
hyperidrosis
10/5/2012
Dr. Rida Akmal 69
DHQ Hospital Fsd

70. Iontophoresis
Contraindicated in those:
1. Who are pregnant
2. Have pacemakers
3. Have metal implants
4. Have cardiac conditions
5. Have epilepsy
10/5/2012
Dr. Rida Akmal 70
DHQ Hospital Fsd

71. Question….
Iontophoresis is NOT used in treating which
type of hyperhidrosis?
a. Palmar
b. Axillary
c. Plantar
10/5/2012
Dr. Rida Akmal 71
DHQ Hospital Fsd

72. Yes!
Iontophoresis can be
used in treating
Palmar and/or Plantar
hyperhidrosis
10/5/2012
Dr. Rida Akmal 72
DHQ Hospital Fsd

73. Try Again!
HINT: Look at these pictures….
10/5/2012
Dr. Rida Akmal 73
DHQ Hospital Fsd

74. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 74
DHQ Hospital Fsd

75. Botox
Botox injections can be used to treat
axillary, palmar, and plantar hyperhidrosis
Analgesic applied prior to injection
Nerve block applied to ulnar or radial
nerve prior to palmar injection
10/5/2012
Dr. Rida Akmal 75
DHQ Hospital Fsd

76. Botox
Starch Iodine test
done prior to injection
Delineates areas of
excess sweating with
black-purple
discoloration of the
skin
10/5/2012
Dr. Rida Akmal 76
DHQ Hospital Fsd

77. Botox
Botox blocks the release of acetylcholine
at the site of the neuromuscular junction.
Sweat glands are not stimulated,
and sweat production ceases
Site of blockage
10/5/2012
Dr. Rida Akmal 77
DHQ Hospital Fsd

78. Botox
Pros:
Lasts 6-7 months
90% effective
Cons:
Very painful to the
palms and soles of
feet
10/5/2012
Dr. Rida Akmal 78
DHQ Hospital Fsd

79. Quick Review
A Starch-Iodine test is done prior to botox
injection.
True
False
10/5/2012
Dr. Rida Akmal 79
DHQ Hospital Fsd

80. Correct!
This test highlights areas of excessive
sweating!
10/5/2012
Dr. Rida Akmal 80
DHQ Hospital Fsd

81. Try Again!
Hint: The test gives a “map,” highlighting
areas of excessive sweating
10/5/2012
Dr. Rida Akmal 81
DHQ Hospital Fsd

82. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 82
DHQ Hospital Fsd

83. Local Excision
Used only for axillary
hyperhidrosis
Starch Iodine test done prior to
excision
Performed under local
anesthesia
Vasoconstrictor applied to
axillary region
Small incisions made
Eisenach, Atkinson, Foley, 2005
10/5/2012
Dr. Rida Akmal 83
DHQ Hospital Fsd

84. Local Excision
Eccrine sweat glands removed through:
Liposuction – suctioned out
Curettage – scraped out
Excision – cut out
Incisions sutured
Pain and bruising to excision site
Eisenach, Atkinson, & Fealey, 2005
10/5/2012
Dr. Rida Akmal 84
DHQ Hospital Fsd

85. Local Excision
 Starch Iodine tests done post excision
show 80% - 90% decrease in sweating
 Has a potential for scarring
10/5/2012
Dr. Rida Akmal 85
DHQ Hospital Fsd

86. Review!
Local Excision is used for what type of
hyperhidrosis?
a. Plantar
b. Palmar
c. Axillary
10/5/2012
Dr. Rida Akmal 86
DHQ Hospital Fsd

87. Correct!
Local Excision is used for axillary
hyperhidrosis!
10/5/2012
Dr. Rida Akmal 87
DHQ Hospital Fsd

88. Try Again!
10/5/2012
Dr. Rida Akmal 88
DHQ Hospital Fsd

89. Topical
Treatment Options
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
10/5/2012
Dr. Rida Akmal 89
DHQ Hospital Fsd

90. Endoscopic Thoracic
Sympathectomy (ETS)
Last treatment option
PERMANENT
Surgery performed under general
anesthesia
10/5/2012
Dr. Rida Akmal 90
DHQ Hospital Fsd

91. 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
Photo used with permission:
Neurosurgical Medical Clinic, Inc
10/5/2012
Dr. Rida Akmal 91
DHQ Hospital Fsd

92. ETS
Small incision made laterally under each
axilla
Incision made through intercostal space
Surgery can be performed on outpatient
basis
However, some patients remain in hospital
for one night
10/5/2012
Dr. Rida Akmal 92
DHQ Hospital Fsd

93. ETS
Ganglion located along
the sympathetic chain
Ganglion formed below
each rib
Ganglion can be divided
= sympathicotomy
Ganglion can be
removed =
sympathectomy
10/5/2012
Dr. Rida Akmal 93
DHQ Hospital Fsd

94. ETS
Ganglion at T2 and T3 = palmar
hyperhidrosis
Ganglion at T3 and T4 = axillary
hyperhidrosis
Ganglion at L2-L4 = plantar hyperhidrosis
10/5/2012
Dr. Rida Akmal 94
DHQ Hospital Fsd

95. 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
10/5/2012
Dr. Rida Akmal 95
DHQ Hospital Fsd

96. 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!
10/5/2012
Dr. Rida Akmal 96
DHQ Hospital Fsd

97. ETS: Side Effects
Surgical complications:
Hemo-pneumothorax requiring chest tube
placement – 1%
Atelectasis
Intercostal neuralgia – 1%
Horner’s Syndrome – 1%
Compensatory Sweating – 60%
Dr. Rida Akmal
10/5/2012 DHQ Hospital Fsd
97

98. Horner’s Syndrome
Stellate ganglion – fusion of C8 and T1
Innervates 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
10/5/2012
Dr. Rida Akmal 98
DHQ Hospital Fsd

99. Horner’s Syndrome
Signs and Symptoms
Unilateral upper eyelid ptosis
Pupil constriction
Facial anhidrosis
10/5/2012
Dr. Rida Akmal 99
DHQ Hospital Fsd

100. Compensatory Sweating
Most frequent
complication – 60% of
post-op patients
Severe sweating noted to
abdomen, chest, back,
and thighs
More severe for those
who live in a hot climate
10/5/2012
Dr. Rida Akmal 100
DHQ Hospital Fsd

101. Compensatory Sweating
Mechanism poorly understood
Theory states:
After excision of T2 and T3, 40% of
body’s sweat function is lost
Body tries to compensate for this loss
10/5/2012
Dr. Rida Akmal 101
DHQ Hospital Fsd

102. Compensatory Sweating
Most patients feel compensatory
sweating is a minor draw-back to
surgery
Sweating to abdomen/trunk =
less interference with daily
activities
Able to write/handle objects
10/5/2012
Dr. Rida Akmal 102
DHQ Hospital Fsd

103. Let’s Review
ETS is performed most often for what type
of hyperhidrosis:
a. Axillary
b. Palmar
c. Plantar
10/5/2012
Dr. Rida Akmal 103
DHQ Hospital Fsd

104. CORRECT!
ETS is performed for palmar hyperhidrosis!
10/5/2012
Dr. Rida Akmal 104
DHQ Hospital Fsd

105. TRY AGAIN!
10/5/2012
Dr. Rida Akmal 105
DHQ Hospital Fsd

106. Question 2
What is the most significant side effect of
ETS?
a. Hemo-pneumothorax
b. Horner’s Syndrome
c. Compensatory Sweating
10/5/2012
Dr. Rida Akmal 106
DHQ Hospital Fsd

107. That’s Right!
Compensatory Sweating can occur in 60%
of post-op patients!
10/5/2012
Dr. Rida Akmal 107
DHQ Hospital Fsd

108. Sorry!
Horner’s Syndrome and Hemo-
pneumothorax only occur in 1% of the
cases!
10/5/2012
Dr. Rida Akmal 108
DHQ Hospital Fsd

109. Treatment Option Review
Hyperhidrosis
AXILLARY PALMOPLANTAR
Topical Treatment
Botox Iontophoresis
Iontophoresis Botox
ETS
Local Excision
Hornberger, 2004
Dr. Rida Akmal
10/5/2012 DHQ Hospital Fsd
109

110. Treatment Option Review
Systemic – blocks
acetylcholine
Dr. Rida Akmal
10/5/2012 DHQ Hospital Fsd
110

111. CONGRATUALTIONS!!
Dr. Rida Akmal
10/5/2012 DHQ Hospital Fsd
111

112. Thank You
Dr. Rida Akmal
10/5/2012 DHQ Hospital Fsd
112