The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis.
TL;DR: These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS), and an international nomenclature should be adopted that refers to the rib levels instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted.
About: This article is published in The Annals of Thoracic Surgery.The article was published on 2011-05-01. It has received 286 citations till now. The article focuses on the topics: Hyperhidrosis & Compensatory hyperhidrosis.
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TL;DR: Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life.
99 citations
TL;DR: The challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).
Abstract: Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).
98 citations
TL;DR: A review of treatment modalities for HH and a sequenced approach are presented and Iontophoresis is considered to be the primary remedy for palmar and plantar HH.
Abstract: Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.
93 citations
TL;DR: This review aims to provide an update on identifying this condition, instigating appropriate management, and when to refer to a specialist.
Abstract: #### Summary points
Primary hyperhidrosis is characterised by sweating in excess of that needed for normal thermoregulation.1 The condition often goes unreported because of embarrassment,2 and management is hindered by a poor evidence base and lack of clinical guidelines. Anxiety about social situations and relationships, and problems with daily living, such as an inability to hold a pen at work, can affect quality of life.3 Hyperhidrosis may be associated with bromhidrosis (unpleasant odour) from the byproducts of bacteria that colonise sweaty areas.4 5 Subjective perceptions of the condition’s impact on the person’s life, and therefore its severity, can make confirmation of diagnosis and effective management challenging.6 This review aims to provide an update on identifying this condition, instigating appropriate management, and when to refer to a specialist.
#### Sources and selection criteria
We searched Medline, Embase, and the Cochrane database. Terms used alone and cross referenced were hyperhidrosis, botulin, iontophoresis, tumescent liposuction, oral therapy, topical therapy, and sympathectomy. We considered reviews, meta-analyses, randomised and non-randomised controlled trials, and large case series (owing to the lack of large volume trials). When possible, we used trials published within the past 10 years. The evidence for many treatments used in primary …
57 citations
Journal Article•
TL;DR: The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life and Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail.
Abstract: Hyperhidrosis is excessive sweating that affects patients' quality of life, resulting in social and work impairment and emotional distress. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use. The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life. The score can be used to guide treatment. Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis. Topical glycopyrrolate is first-line treatment for craniofacial sweating. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis. Iontophoresis should be considered for treating hyperhidrosis of the palms and soles. Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail. Local microwave therapy is a newer treatment option for axillary hyperhidrosis. Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies.
54 citations
Cites background or methods from "The Society of Thoracic Surgeons ex..."
...Because hyperhidrosis is thought to be secondary to excessive sympathetic stimulation, endoscopic thoracic sympathectomy has been used to treat severe cases of hyperhidrosis.(28) This procedure, which has evolved from an open procedure to an endoscopic one, involves cutting or clipping sympathetic nerves....
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...This procedure, which has evolved from an open procedure to an endoscopic one, involves cutting or clipping sympathetic nerves.(28) Referral for endoscopic thoracic sympathectomy may be indicated when less invasive therapies are ineffective....
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...Referral for endoscopic thoracic sympathectomy may be indicated when less invasive therapies are ineffective.(4,9,28) Although the procedure decreases or eliminates sweating in the original problem area, a common late complication is compensatory sweating in other areas, usually in the abdomen, back, gluteal region, and legs....
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References
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TL;DR: Intradermal injection of botulinum toxin A is an effective and safe therapy for severe axillary hyperhidrosis and 98 percent of the patients said they would recommend this therapy to others.
Abstract: Background Treatment of primary focal hyperhidrosis is often unsatisfactory. Botulinum toxin A can stop excessive sweating by blocking the release of acetylcholine, which mediates sympathetic neurotransmission in the sweat glands. Methods We conducted a multicenter trial of botulinum toxin A in 145 patients with axillary hyperhidrosis. The patients had rates of sweat production greater than 50 mg per minute and had had primary axillary hyperhidrosis that was unresponsive to topical therapy with aluminum chloride for more than one year. In each patient, botulinum toxin A (200 U) was injected into one axilla, and placebo was injected into the other in a randomized, double-blind manner. (The units of the botulinum toxin A preparation used in this study are not identical to those of other preparations.) Two weeks later, after the treatments were revealed, the axilla that had received placebo was injected with 100 U of botulinum toxin A. Changes in the rates of sweat production were measured by gravimetry. Res...
382 citations
TL;DR: For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavicular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.
Abstract: One hundred patients with primary palmar hyperhidrosis (HH) underwent bilateral upper dorsal sympathectomy (UDS) by the supraclavicular approach. Pre-operative epidemiological and clinical data are described. The immediate and late results, as well as the complications and side-effects are detailed. Follow-up was completed on 93 patients between four and 50 months after the operation (average 18 months). Of 93 patients, 91 had drying of the hands. In 58% some moisture returned to the hands but in no case did the hyperhidrotic state recur. Subjective patient evaluation was excellent or good in 83 patients (89%) and only one patient (a technical failure) was completely dissatisfied. Reasons for some degree of dissatisfaction with operation were mainly compensatory HH in non denervated areas, and Horner's syndrome. Compensatory HH usually decreased with passage of time and, permanent Horner's syndrome occurred in 8% of patients (4% of procedures). Technical failure can be avoided by use of frozen section examination intraoperatively. For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavicular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.
311 citations
"The Society of Thoracic Surgeons ex..." refers background in this paper
...It is believed that idiopathic focal hyperhidrosis affects 1% to 3% of the population, with a predominance in countries such as Taiwan that are near the Equator [2, 3]....
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TL;DR: Botulinum toxin type A was significantly better than placebo on all measures of sweating Patient satisfaction was high and few adverse events were reported Effects of treatment remained apparent at 16 weeks.
Abstract: Objectives: To evaluate the safety and efficacy of botulinum toxin type A in the treatment of bilateral primary axillary hyperhidrosis. Design: Multicentre, randomised, parallel group, placebo controlled trial. Setting: 17 dermatology and neurology clinics in Belgium, Germany, Switzerland, and the United Kingdom. Participants: Patients aged 18-75 years with bilateral primary axillary hyperhidrosis sufficient to interfere with daily living. 465 were screened, 320 randomised, and 307 completed the study. Interventions: Patients received either botulinum toxin type A (Botox) 50 U per axilla or placebo by 10-15 intradermal injections evenly distributed within the hyperhidrotic area of each axilla, defined by Minor9s iodine starch test. Main outcome measures: Percentage of responders (patients with ≥50% reduction from baseline of spontaneous axillary sweat production) at four weeks, patients9 global assessment of treatment satisfaction score, and adverse events. Results: At four weeks, 94% (227) of the botulinum toxin type A group had responded compared with 36% (28) of the placebo group. By week 16, response rates were 82% (198) and 21% (16), respectively. The results for all other measures of efficacy were significantly better in the botulinum toxin group than the placebo group. Significantly higher patient satisfaction was reported in the botulinum toxin type A group than the placebo group (3.3 v 0.8, P 0.05). Conclusion: Botulinum toxin type A is a safe and effective treatment for primary axillary hyperhidrosis and produces high levels of patient satisfaction. What is already known on this topic Primary hyperhidrosis is a chronic disorder that can affect any part of the body, especially the axillas, palms, feet, and face Current treatments are often ineffective, short acting, or poorly tolerated What this study adds Botulinum toxin type A was significantly better than placebo on all measures of sweating Patient satisfaction was high and few adverse events were reported Effects of treatment remained apparent at 16 weeks
310 citations
"The Society of Thoracic Surgeons ex..." refers background in this paper
...Botulinum toxin type A (Botox) and type B (Myobloc) ave been shown to be effective for axillary and palmar yperhidrosis [14, 15]....
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TL;DR: Thoracic sympathectomy is a simple, effective, safe method for the treatment of hyperhidrosis, resulting in an improved quality of life for patients, and this change in the questionnaire documents this change.
298 citations
"The Society of Thoracic Surgeons ex..." refers background or methods in this paper
...An example of the data collection sheets used by de Campos and associates [1] in an effort to standardize results can be found at http://www....
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...It may develop secondary to a variety of medical disorders or it may be primary or cryptogenic, with symptoms such as focal hyperhidrosis usually affecting the palms, axillae, or the feet [1]....
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TL;DR: The long-term outcome after endoscopic thoracic sympathectomy from below D1 to D4, using a single-site access technique for primary hyperhidrosis of the upper limbs was evaluated, with particular emphasis on patient satisfaction.
Abstract: ObjectiveThis evaluated the long-term outcome after endoscopic thoracic sympathectomy (ETS) from below D1 to D4, using a single-site access technique for primary hyperhidrosis of the upper limbs.Summary Background DataPrimary hyperhidrosis of the upper limbs is a distressing and often socially disab
239 citations