Hyperhidrosis is excessive sweating that most commonly occurs in the hands (palmar hyperhidrosis), axillae (axillary hyperhidrosis), and feet (plantar hyperhidrosis). This occurs in about 3% of the population and 6% of Asians. In 40% of patients, other members of the family also suffer with hyperhidrosis. The excessive sweating is usually intermittent but can be continuous. It usually increases with stress and elevated temperature.
The basic problem with hyperhidrosis is over-activity of the sympathetic nervous system. This leads to excessive stimulation of sweat glands and vasoconstriction (narrowing) of arteries. Ironically, at the same time when the excessive stimulation to the sweat glands makes the hands wet, this means that decreased blood flow to the hands makes them cold and clammy.
Hyperhidrosis can be caused by other diseases, including obesity, increased thyroid function, etc. or a primary problem. However, the most hyperhidrosis is not due to other medical problems.
- A man working in a warehouse where a box that slipped out of his wet hands fell on his foot and broke his toe,
- A policeman whose gun slipped out of his wet hands during a shootout,
- The 12-year-old girl with whom no one would dance because she was the girl with the cold, wet hands.
- The woman whose car’s wheels hit the curb when the steering wheel slipped in her wet hands
- A woman’s palms sweat so much that she could fill her cupped hands with sweat.
- While working at a furniture manufacturing company, the grease and sweat from a woman’s hands damaged the unstained furniture.
Palmar hyperhidrosis can be a severely debilitating problem. Wet hands are extremely embarrassing when shaking hands with people so it severely interferes with social and business activities.
Axillary sweating can be so severe that patients that people have to change their shirts several times per day, wear only dark colors that do not show the sweat as much and avoid certain materials, such as silk, that are destroyed by the sweat.
Pedal sweating may cause the foot to slip off the brake when driving a car, slip in a sandal to cause a twisted ankle or fill a shoe with sweat so that the shoe cannot be worn on consecutive days.
There is no blood test or x-ray to diagnose hyperhidrosis. A starch test can be performed on hands but is rarely done. The diagnosis is made by the history from the patient describing the problems caused by hyperhidrosis.
There are many non-surgical treatments that can be tried for patients with significant hyperhidrosis.
- Drysol: Aluminum Chloride is applied to hands daily at night. Leave on for 6-8 hours.
- Botox: Botox injections have been used for the hands and the axillae. For the hands and axillae, the treatment requires many injections of Botox during a single session. These are usually effective in reducing the sweat, but the treatment lasts for 3-6 months.
- Iontophoresis is a system to place hands or feet in water with low voltage DC electrical current. It is done 30 minutes, three days per week. For patients for whom it works, the benefit is temporary. When the treatment is stopped, the hyperhidrosis returns.
- Anti-anxiety drugs have been tried, but they have very little role in the treatment of hyperhidrosis because, while the sweat may increase with tension and anxiety, they are not the cause of the problem.
- Psychotherapy has been tried, but has very little role in the treatment of hyperhidrosis because, while the sweat may increase with tension and anxiety, they are not the cause of the problem.
- Drying medicines: There are pills that can be taken to dry up the sweating, however, patients complain that these medicines cause dry mouth and dry eyes.
Surgical Treatment (sympathectomy)
- Surgery for hyperhidrosis has been performed for 70 years. Originally, the 2-hour procedure required a chest incision and spreading the ribs, and only one side was done during an operation. That was painful and required admission to the hospital. Currently, the procedure is performed with minimally invasive surgery and as an outpatient. There are several methods for surgical treatment of hyperhidrosis, including cutting the nerve, clipping the nerve, and removing the nerve. The most common method is cutting the nerve.
Benefits of the Operation: Almost all patients have a substantial reduction in the sweaty hands after the operation. The improvement in the axillary and pedal sweating is much less consistent (about 50% success) and not predictable. Normally, patients have mild chest pain for a few days (though it can last longer or be severe). They can usually return to work in a few days.
Side Effects of Sympathectomy: While the procedure is usually performed with low risk on an outpatient basis, there are risks to every procedure.
Compensatory hyperhidrosis which means that they experience increased sweating in other areas of the body, such as the scalp, chest wall, thighs, or feet, occurs in most patients to some degree. The increased sweating may decrease inthe months following the operation and patients usually do not mind mild increased sweating because the severely debilitating hand sweating has improved so much. About 5% of patients experience severe compensatory sweating. Some patients may find this so severe that they are unhappy that they underwent the procedure. The different techniques for the procedure were developed to reduce the side effects.
Horner’s Syndrome (droopy eyelids) occurs in about 1% of people. If this occurs, it may be temporary or may require eye surgery to correct the droop. Patients also have the usual risks of any operation, including bleeding, infection, collapsed lung etc.
Other indications for Sympathectomy
- Sympathectomy for heart arrhythmias (ventricular fibrillation): There are other indications for sympathectomy. In some cases, medicines fail to stop ventricular fibrillation.
- Sympathectomy for pancreatic pain: