t h e s u r g e o n x x x ( 2 0 1 5 ) 1 e7

Available online at www.sciencedirect.com

ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net

Axillary hyperhidrosis: A review of the extent of the problem and treatment modalities Sanjay Singh*, Harriet Davis, Paul Wilson Department of Vascular Surgery, Royal Lancaster Infirmary, Lancaster, LA1 4RP, UK

article info

abstract

Article history:

Background: The purpose of this review is to summarize the extent of the problem of

Received 10 May 2014

axillary hyperhidrosis and treatment modalities available. The benefits and disadvantages

Received in revised form

of various treatments are reflected on with the hope of providing a starting point to

24 October 2014

investigate new ways of treating hyperhidrosis.

Accepted 24 March 2015

Material & methods: A literature search was conducted using various databases and search

Available online xxx

criteria. Results: Current treatments include aluminium chloride antiperspirants, iontophoresis,

Keywords:

botox injections and endoscopic thoracic sympathectomy. Botox therapy is usually the

Axillary hyperhidrosis

most effective treatment, without surgery or unpleasant side effects. However it has to be

Ionophoresis

administered by a skilled clinician and involves around 20 injections to treat axillary hy-

Thoracic sympathectomy

perhidrosis. Other ways of giving Botox are being developed, the most promising one being

Microneedles

the use of microneedles which are able to penetrate the skin and deliver drugs to the target area of the dermis without causing pain. In comparison to the temporary effects of microneedles, laser and microwave therapies are also assessed as they offer the hope of permanent relief from hyperhidrosis. Conclusion: There is a considerable dearth in the literature on the management of axillary hyperhidrosis. Further study in larger populations with longer follow up times is critical to access the long term effects of treatment. Microneedles could be the future treatment of choice with the potential to deliver drugs in a safe and pain free way. © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction Sweating is a necessary mechanism utilised by every person for thermoregulation. In about 1e3% of the population sweating becomes a hindrance to daily functioning as the body produces more sweat than is needed to control body temperature.1,2 Hyperhidrosis is a condition that causes

excessive sweating, usually from the palmar, plantar or axillary surfaces.3 The exact mechanism underlying the condition is poorly understood but it is thought to be caused by sympathetic overstimulation of the eccrine sweat glands. Secondary hyperhidrosis can also occur but this is more easily treated as the underlying cause, drugs or febrile illness such as diabetes mellitus or menopause can be addressed.3 Hyperhidrosis may not be a life threatening condition; however it can

* Corresponding author. Tel.: þ44 7877158782. E-mail address: [email protected] (S. Singh). http://dx.doi.org/10.1016/j.surge.2015.03.003 1479-666X/© 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Singh S, et al., Axillary hyperhidrosis: A review of the extent of the problem and treatment modalities, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.03.003

2

t h e s u r g e o n x x x ( 2 0 1 5 ) 1 e7

increase the risk of cutaneous infection and have a significant social and psychological impact on the person affected.4 Treatment options vary depending on affected site, with aluminium chloride and iontophoresis being the first and second options, respectively, for palmar sweating. A similar algorithm is used in the treatment of plantar hyperhidrosis. As iontophoresis requires the skin to be slightly submerged in water, this presents a challenge in treating more severe axillary hyperhidrosis. If a person's sweating is unresponsive to aluminium chloride antiperspirants, the second line of treatment in axillary hyperhidrosis is frequently Botox injections.1 Although the botulinum toxin is effective in reducing sweating the treatment can be uncomfortable, involving 15e20 injections and needs to be repeated every 3 months by a skilled clinician.5,6 The main drawback of botulinum toxin injection is pain which can be reduced by topical administration of local anaesthetic agents.

Pathophysiology Sweating occurs when the eccrine sweat glands are activated by acetylcholine released from cholinergic, sympathetic nerves causing an influx of calcium into the cell. There is a complex exchange of calcium, sodium, potassium and chloride ions resulting in secretion of NaCl into the primary fluid before this is reabsorbed leaving a hypotonic fluid.7 Hyperhidrosis occurs due to “autonomic neuronal dysfunction”.8 The sympathetic nerves run from the cerebral cortex to the hypothalamus, through the lateral horn of the spinal cord and to post ganglionic fibres. It is thought that the nerves supplying the palms, feet and axilla are controlled distinctly from nerves in other parts of the hypothalamus and receive no regulation by thermosensitive areas; these nerves are controlled mainly by emotional centres. Hence it is believed that hyperhidrosis is due to abnormal central control of emotions.8 Thermoregulatory sweating occurs during the day and night, whereas emotional sweating is restricted to the daytime. Emotional sweating is controlled by the anterior cingulate cortex, of the hypothalamus. The area that controls emotional sweating runs predominantly to the palms, soles of feet, forehead, scalp and axilla, further supporting the belief that hyperhidrosis is caused by an irregular control of emotions.9

Diagnosis and clinical presentation Hyperhidrosis may be primary or secondary; the former is relatively common, affecting between 0.6% and 1% of the general population.10,11 Primary or focal hyperhidrosis is found to start during adolescence or even before and seems to be inherited as anautosomal dominant genetic trait. The palms, soles and axillae are the most commonly affected sites. In upper limb hyperhidrosis, the axillae alone are affected in 37%, the hands and axillae in 43% and the hands alone in 20 per cent.11 e inherited as anautosomal dominant or generalised hyperhidrosis (affecting the whole body) can be caused by some illnesses including infections, and by some hormonal conditions including menopause, diabetes and an overactive thyroid gland. Some medicines such as antidepressants can

also cause excessive sweating. Sometimes no cause can be found. (Table 1) shows the criteria for diagnosing hyperhidrosis.12 A detailed comprehensive history and sufficient knowledge of the disease is required to make a diagnosis and to be able to differentiate between primary and secondary hyperhidrosis.13 For treatment purposes a starch-iodine test can be used to demonstrate the actively secreting foci.7 Quantification of the amount of sweat secreted is determined gravimetrically, where a piece of filter paper is placed in the affected area and using a scale the paper is weighed before and after use by the patient. This allows for calculation of amount of sweat produced in a defined period of time and is frequently used to track the effectiveness of treatment.12

Impact on the quality of life With hyperhidrosis causing no real threat to life, and in an ever cost conscious society, some may argue that it is not worth treating. However it is important to remember the person with the condition can suffer from severe psychological and social issues.14 Several studies have reported an improvement in quality of life for patients following treatment for hyperhidrosis by using the Hyperhidrosis Disease Severity Scale (HDSS) (Table 2).15e17 The HDSS is a four part questionnaire that provides a quantitative measure of disease severity and impact on life before and after treatment. As well as the emotional impact, excessive sweating can leading to some physical complications, including increased risk of dermatophytosis and keratolysis as well as associations with atopic dermatitis.4 This provides further evidence that hyperhidrosis has important clinical complications and may be worthy of further research into effective treatments.

Existing treatment modalities According to the National Institute for Health and Care Excellence, general lifestyle advice and aluminium chloride anti-perspirants should be the first line of treatment. If sweating persists more topical treatments and iontophoresis can be used although this is less easily achieved in the axilla.18 For this reason, severe axillary hyperhidrosis is often treated using botulinum toxin administered via intradermal injections. Further surgical options are available but tend to have more side effects. The mechanism & levels of exciting treatments is shown in Fig. 1.

Topical aluminium chloride Aluminium chloride treatments are low cost and convenient and are therefore used as the first line of treatment. They work by causing atrophy of the secretory cells in the eccrine gland and blocking the epidermal duct. The initial dose is a10-20% solution which can be increased to a 35% solution dissolved in ethyl alcohol or a 2e4% salicylic acid gel.19 The most common adverse effects of aluminium chloride treatment are itching and stinging immediately after application and ongoing skin irritation.20 In one series of 691 patients, pruritus

Please cite this article in press as: Singh S, et al., Axillary hyperhidrosis: A review of the extent of the problem and treatment modalities, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.03.003

t h e s u r g e o n x x x ( 2 0 1 5 ) 1 e7

Table 1 e Criteria for diagnosing hyperhidrosis.  Onset of symptoms in childhood or adolescence (