The RBCs of vascular surgeryRepair, Bypass and Chemistry of the vascular systemHYPERHIDROSISHyperhidrosisIs a pathological condition characterised by excess sweating commonly affecting the axillae, palms of the hands and soles of the feet. It may also affect the face and the perineum. It can cause significant disruption to work and social life - wetness and staining of clothes, sodden shoes and difficulties in performing simple tasks like handling paper or holding a pen. It causes embarrassment and social isolation. Primary hyperhidrosis affects about 1% of the population, usually young adults, but may persist into adult life. Pathophysiology Sweating is controlled by circulating catecholarmines and sympathetic innervation where the main neurotransmitter is acetylcholine. Sweating is mediated mainly by eccrine glands found in greatest density in the axillae, palms and soles. Each gland consists of a coiled sccrctory part located within the dermis, surrounded by a capillary plexus and supplied by sympathetic post ganglionic fibres (see diagram). Central control is via the hypothalamus. The head and neck are supplied by T2 to T4, the upper limbs by T2 to T8 and the lower limbs by T11 to L2 sympathetic ganglia. Eccrine sweat glands are also stimulated by cholinergic as well as a adrenergic agonists. Treatment
1. Topical applications. These include aluminium chloride and
glutaralderhyde. These reduce sweating by blocking the excretory ducts of
sweat glands. They can be useful in treating local hyperhidrosis e.g.
face. However, they need frequent application, are messy and often cause
skin irritation. Glutaralderhyde causes brown staining of the skin. 3. Systemic / topical anticholinergics. Favourable results have been reported with topical 0.5% glycopyrrolate solution. This is an anti-cholinergic agent similar to but 5 to 6 times more potent than atropine. It inhibits acetycholine. It is especially good for facial hyperhidrosis. Anti-cholinergics have side effects like dry mouth, blurred vision and urinary retention but this applies mainly to systemic forms. 4. a adrenergic blockers. Some success had been recorded with phenoxybenyamine in doses of 10-40mg twice a day. It works by binding to c adrenergic receptors. The main side effects are orthostatic hypotension and inhibition of ejaculation. 5. Botulism toxin. This is a fairly new form of treatment and works by blocking the release of acelytchline and hence synaptic transmission. It thus produces chemical denervation of the sweat gland. It is useful to treat focal areas of hyperhidrosis. It is applied by multiple injections into the hyperhidrotic areas. Injections are spaced 1-2.5cm apart. For an axilla or palm, about 50 units of toxin need to be injected. This brings about a 70-80% reduction in sweating in the axilla, but only 25-30% in the palms. A treatment lasts 3-8 months, but this can be prolonged to 1 year with higher doses. Side effects include weakness of small muscles of the hand and face (if used here). Multiple injections also cause significant discomfort. It is probably best used in the axillae as it is better tolerated here and there is no real risk of muscle weakness.
l. Excision of axillary tissue. This may involve excision of
subcutaneous tissue alone or removal of skin and the RBCs byNeil Browning, FRCSPublished By: The Julie Andrews Vascular Unit Ashford
& St. Peter's Hospitals NHS Trust
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