Hyperhidrosis Hyperhidrosis (excessive sweating) is a medical condition that can be loosely defined as sweating inordinately beyond the physiological need. Sweating is necessary for the regulation of body temperature. There are two types of sweat glands: apocrine glands, which emit perspiration, and eccrine glands, which produce sweat and regulate body temperature. There are about five million eccrine glands in the human body, and about two million of these are in the hands. Sweat production is controlled by the Sympathetic Nervous System, a portion of the involuntary nervous system. Depending on its causes or origin, hyperhidrosis is classified as primary or secondary. Primary Hyperhidrosis is a medical condition that, in severe states, can lead to intractable and profuse sweating in several locations of the body. The illustration on the left shows the areas most commonly affected: the palms of the hands, axillae (arm pits) and the soles of the feet. Occasionally the face, groin, and legs are involved. Primary hyperhidrosis is diagnosed when there is no known cause for the symptoms. In contrast, Secondary Hyperhidrosis is the result of an underlying condition, and usually affects the whole body. Symptoms In Primary Hyperhidrosis excessive sweating most often involves the hands, feet, and the axillae (arm pits), but there are some instances in which the face, groin, and legs are involved. Unexplained profuse sweating without any stimulus may start any time between infancy and adulthood, usually during adolescence. Many individuals suffering from the condition with any degree of severity constantly carry a towel or handkerchief in their hands. You may have shaken hands with people suffering from hyperhidrosis. It is impossible to tell if someone with clammy sweaty hands is nervous and anxious, or if they are suffering from hyperhidrosis. The symptoms of hyperhidrosis are totally unrelated to temperature and stress, although both temperature and stress may exacerbate the problem. Individuals with primary hyperhidrosis may sweat profusely during the most severe winter days, or in very cold air conditioned rooms. Their sweating may be brought on or aggravated by stress, it or may be spontaneous and excessive. The sweating may become so severe that patients with acute hyperhidrosis can fill a coffee cup with sweat from their hands without any stimuli. In Secondary Hyperhidrosis the sweating may not be as profuse, and generally involves the whole body. Causes Primary Hyperhidrosis, also known as essential or idiopathic (of unknown cause) hyperhidrosis, is caused by an overactive sympathetic nervous system. The portion of the sympathetic nervous system that controls the apocrine and eccrine glands is called the Thoracic Sympathetic Ganglion Chain. This is a chain of nerve nodes that runs inside the chest cavity along either side of the vertebral spine as illustrated. When the Thoracic Sympathetic Ganglions become overactive, the result is the profuse excessive sweating we call Primary Hyperhidrosis. Some of the conditions which may lead to secondary hyperhidrosis are: Hyperthyroidism (over active thyroid gland) Various other endocrine diseases Certain cancer treatments Menopause (usually associated with "hot flashes") Obesity Certain psychiatric disorders Treatment Secondary Hyperhidrosis Victims of hyperhidrosis should first consult their family physicians to rule out the possibility of underlying causes. Once the underlying cause is identified and treated, the symptoms of secondary hyperhidrosis usually disappear. Patients undergoing hormonal treatment for prostatic cancer may at times suffer disturbing sweat attacks. These patients can get relief from antiestrogens such as ciproterone acetate. Likewise, women undergoing menopause ("life change") and suffering from excessive sweating during "hot flashes" may benefit from hormonal treatment. Primary Hyperhidrosis In many patients the underlying cause cannot be identified. This then is when the condition should be diagnosed as Primary Hyperhidrosis. Some of the treatments that have been used for the symptoms of primary hyperhidrosis are listed below. Psychotherapy Many patients suffering from primary hyperhidrosis have reported poor results form psychotherapy. The reason is that, although the symptoms may be aggravated by emotional stress, the stress is usually caused by the hyperhidrosis condition, which leads to embarrassing, stressful situations. What patients seem to benefit the most from psychotherapy is learning how to live with the condition without additional stress. Antiperspirants In mild cases of primary hyperhidrosis the sweating can some times be controlled by extra-strength antiperspirants. The most effective type of antiperspirant is usually aluminum chloride. The disadvantage is that patients usually have to buy specialty antiperspirants at a premium price. Antiperspirants need to be applied to the affected areas with regularity, and when the affected areas include the hands, there is the additional disadvantage that a white powdery layer is sometimes visible. Medication Unfortunately, there are no known drugs for the specific treatment of primary hyperhidrosis. Different types of drugs have been used to attempt to control hyperhidrosis, but unfortunately, these drugs have significant side effects that are usually not tolerated by patients. The types of drug most often prescribed for the symptoms of hyperhidrosis are psychotropic (sedative) and anticholinergic (atropine, robinal). The usual side effects of anticholinergic drugs in a sufficient dose to have a noticeable effect on hyperhidrosis are a very dry mouth, urinary retention, and loss of accommodation of the eyes. Some patients slur words because of the dryness of the mouth. Extensive and prolonged use of anticholinergic drugs can also increase the risk of a heat stroke because sweating, the body's normal cooling function, is blocked. In severe cases of primary hyperhidrosis all medical treatment may be futile. Electrophoresis A treatment called Electrophoresis or Iontophoresis can provide temporary relief in mild cases of primary hyperhidrosis. The treatment consists of applying a low intensity electrical current to the affected areas. Because the areas to be treated are immersed in an electrically conducting solution, the treatment is only practical for the hands and feet. The results are satisfactory for some individuals suffering from mild symptoms. However the disadvantages are many. The electric current is uncomfortable, and many patients find the treatment expensive, time consuming, and the results not lasting long enough. The treatment usually lasts about half an hour and three or four sessions per week may be required. The frequency of sessions may be lessened with time, but a program of regular treatments must be maintained indefinitely to control the symptoms of mild hyperhidrosis. Another disadvantage of this treatment is that it can not be applied to other affected areas such as the axillae, legs, or groin. Laser Abrasion Although effective in the treatment of many other skin conditions, this therapy is totally ineffective for the control of primary hyperhidrosis. Some patients have reported suffering third degree burn lesions resulting in heavy scarring after undergoing this procedure, only to find out later that it had no effect on their profuse sweating. Hypnosis Most patients who have tried this method of treatment have reported unsatisfactory results. The reason seems to be that primary hyperhidrosis is the result of a functional deficiency in a part of the sympathetic nervous system which controls sweating and is not subject to direct mind control. Removal of Sweat Glands This procedure is only effective in the treatment of axillary hyperhidrosis, and may leave significant scarring. For a person suffering of primary hyperhidrosis, this approach is usually only a partial solution to the problem, especially since the most annoying areas usually are the hands. Open Thoracic Sympathectomy This treatment involves the surgical removal of the thoracic sympathetic ganglions, usually T2 -T4, which are the cause of the problem. Although surgical thoracic sympathectomy has been known to effectively control primary hyperhidrosis, this procedure has not been used extensively due to the fact that, until now, the risks involved with the surgery greatly outweighed the benefits obtained in correcting an otherwise benign condition. The technique used until recently, Open Thoracic Sympathectomy, is major surgery requiring a hospital stay of five to seven days, and a month convalescent period. There are two techniques used in Open Thoracic Sympathectomy: the dorsal approach (from the back) and the frontal approach. Both procedures require large incisions (7 inches/18 cm to 12 inches/30 cm in length), and the frontal approach involves cracking the patient's ribs. As with any major surgery, the recuperation period can be very painful. Minimally Invasive Sympathectomy Fortunately, current advanced endoscopic techniques now allow for the treatment of this condition with a convenient outpatient procedure. Specially trained surgeons use this minimally invasive procedure, known as Thoracoscopic Sympathectomy or Endoscopic Thoracic Sympathectomy or Video Assisted Thoracic (VAT) Sympathectomy (VATS) or Video Assisted Endoscopic Thoracic Ganglionectomy, to remove the Thoracic Sympathetic Ganglions which cause primary hyperhidrosis. The procedure takes about 20 minutes, and requires only a Band-Aid size (1/4 in / 5 mm) incision. Patients are admitted to the hospital on an outpatient basis, are fully anesthetized, and usually go home the same day. Relief of hand and armpit sweating is immediate in most of the cases, and foot sweating is also relieved in many of the cases. In cases when facial sweating and spontaneous facial blushing are present these symptoms may also disappear. While every surgical procedure has some degree of risk associated with it, Endoscopic Thoracoscopic Sympathectomy, when performed by an experienced, skillful surgeon, is a very safe procedure with minimal side effects. The most common side effect is compensatory hyperhidrosis. This is a a moderate increase in sweating in other parts of the body. Most commonly the chest and the back of the legs are affected. This condition is tolerable for most patients and fewer than 10% describe this as "troublesome". Most patients with compensatory hyperhidrosis report that this sweating improves with time. A rare side effect is "gustatory sweating"; a condition which leads to the sensation of sweating when eating . This may occur without actually sweating. Another possible complication in this procedure is Horner's Syndrome, although the frequency of occurrence is extremely low in the hands of an experienced surgeon. Horner's Syndrome results in a slightly smaller pupil and a slightly drooping eyelid on the affected side. A reduction in the resting and/or exercise heart rate may also occur. Postoperative residual pneumothorax is a possible complication that nearly always resolves on its own without further treatment necessary. Bleeding and/or parenchymal lung injury are also possible complications, but again are unusual in the hands of a surgeon experienced in this procedure. Robotics Assistance Dr. Jim S. Garza, of the VideoScopic Surgery Center, in Houston, Texas, has performed over 350 of these procedures since 1991 on patients ranging in age from 13 to 79 years. Dr. Garza also uses advanced endoscopic techniques to surgically treat chronic heartburn caused by Gastro Esophageal Reflux Disease (GERD), which is often associated with Hiatal Hernia and sometimes Achalasia. He also uses the laparoscopic (endoscopic) techniques in gallbladder surgery and to repair Inguinal Hernias. Dr. Garza has performed over 2000 videoscopic procedures since 1991. For more information on this procedure, appointments, or for patient referral, you are invited to contact Dr. Jim S. Garza at the VideoScopic Surgery Center. We will be glad to answer your questions and arrange for an initial consultation.