1. hyperhidrosis dr abbas pardakhty 2011 kerman faculty of pharmacy 2
Post on 21-Jan-2016
215 Views
Preview:
TRANSCRIPT
1
Hyperhidrosis
Dr Abbas Pardakhty2011
Kerman Faculty of Pharmacy
2
Sweat Glands
The human body has 2-5 million sweat glandsTwo main types:
3
ECCRINEAPOCRINE
Source: www.sweathelp.org
Eccrine Sweat Glands
Approximately 3 million eccrine sweat glands
Secrete a clear, odorless fluidAid in regulating body
temperatureAreas of concentration:
Facial, plantar, and axillae
4
Source: www.sweathelp.org
Apocrine Sweat Glands
Inactive until pubertyProduce thick fluid
Secretions come in contact with bacteria on the skin
and produce characteristic “body odor”
Found in axillary and genital areas
5
Source: www.sweathelp.org
Sweating
The hypothalamus serves as the thermoregulatory center
It controls both blood flow and sweat output to the skin’s surface
6
Source: www.sweathelp.org
Sweating
The hypothalamus can be triggered by:
7
EXERCISE
TEMPERATURE CHANGE
STRESS
HORMONESSource: www.sweathelp.org
Sweating
8
Once triggered, the hypothalamus sends messages down the
spinal cordvia neurotransmitters.
Source: www.sweathelp.org
SweatingThe neurostransmitters travel down the spine
via ganglion or sympathetic nerves
These ganglion travel to nerves, which reach the skin’s surface
9
Photo used with permission: The Whiteley Clinic,2007
Source: www.sweathelp.org
Neurotransmitters
10
Neurotransmitters act as “vehicles,” transmittinginformation from the hypothalamus to the skin’s surface.
Photo used with permission: The Whiteley Clinic, 2007
NeurotransmittersThe neurotransmitters can “exit” at various
places along the spinal cord.
The “exit” determines the location of skin innervation.
11
Spinal Cord Innervations
12
T2 – T8 innervate the skin of the upper limbs
T2-T4 innervatethe skin of the face
T4-T12 innervate theskin of the trunk T10-T12 innervate the skin
of the lower limbs
Source: www.sweathelp.org
Neurotransmitters
13
Acetylcholine innervates
Eccrine Sweat Glands
Catecholaminesinnervate
Apocrine Sweat Glands
Source: www.sweathelp.org
Sweating
Once innervated, the apocrine and eccrine glands will produce.…
SWEAT!
14
Source: www.sweathelp.org
What is Hyperhidrosis?
•Sweating that is more than required to maintain normal thermal regulation
15
Sweating Nomenclature
•Areas: Focal, regional, generalized•Symmetry: Symmetric or asymmetric•Classification: Primary vs. secondary•Type of sweating: Anhidrosis, euhydrosis,
hyperhidrosis
16Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
17
Hyperhidrosis
Causes of Generalized Hyperhidrosis
Usually secondary in nature•Drugs (Venlafaxine, ...), toxins, substance abuse•Cardiovascular disorders•Respiratory failure•Infections•Malignancies
•Hodgkin’s, myleoproliferative disorders, cancers with increased catabolism
•Endocrine/metabolic disorders•Thyrotoxicosis, pheochromocytoma, acromegaly, carcinoid tumor,
hypoglycemia, menopause
• Rarely Idiopathic / Primary HH
18
Causes of Localized Hyperhidrosis
•Usually Idiopathic / Primary•Social anxiety disorder•Eccrine nevus•Gustatory sweating•Frey syndrome•Impaired evaporation•Stump hyperhidrosis after amputation
19
20
Idiopathic (Primary) Focal Hyperhidrosis
21
Mean Age of Onset
Diagnosis of Primary Focal Hyperhidrosis
•Focal, visible, excessive sweating of at least 6 months duration without apparent cause with at least 2 of
the following characteristics :–Bilateral and relatively symmetric–Impairs daily activities–Frequency of at least one episode per week–Age of onset less than 25 years–Positive family history–Cessation of focal sweating during sleep
22Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003.
Diagnostic Work-up
•History–Age of onset–Location–Trigger factors–Review of symptoms
•Physical exam•Laboratory evaluation
–Gravimetric– 1° research tool–Starch iodine – defines area of disease
23
Starch iodine test, with the darkened area showing location of excessive sweating
24
Axillary Sweat Production
1° hyperhidrosis patients healthy controls
346.0
Hund et al. Arch Derm 2002;138(4):539-41
DLQI Total Scores and Ranges by Dermatological Disease/Condition
Diseases with DLQI Scores 10 or Greater
DiseaseDLQI Score (baseline)
Hyperhidrosis palms18–8.8Hyperhidrosis axillary17–10
Eczema (inpatient)16.2Focal hyperhidrosis (general)15.5–9.2
Psoriasis (inpatient)13.9Hyperhidrosis forehead12.5
Atopic eczema12.5–5.8Psoriasis (outpatient)11.9–4.51
Contact dermatitis10.8Pruritus10.5–10
25 Spalding et al. Value in Health 2003;6(3):242(abstract)
Scores range from 0 to 30, with 30 indicating the worst quality of life.
Summary
Primary Focal Hyperhidrosis is a separate and unique disease
26
•Bilateral & symmetricBilateral & symmetric•Axilla, palms, soles, craniofacialAxilla, palms, soles, craniofacial•Onset in childhood and Onset in childhood and adolescenceadolescence•Significant impact on quality of Significant impact on quality of lifelife•Effective therapiesEffective therapies
TreatmentTreatment
27
Available Treatments
•Topical agents•Iontopheresis•Systemic agents
–anticholnergic
•Botulinum toxin•Surgery
–Local excision/currettage–Thoracic sympathectomy
28
29
Treatment Response
Treatment Options
30
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the first treatmentoption to begin!
Topical TreatmentFirst line treatment
Aluminum Chloride Hexahydrate antiperspirant of choice
Most beneficial for axillary hyperhidrosis
Can be used for plantar and palmar
31
Photos used with permission:www.feelbest.com
Hornberger, 2004
Topical Treatment:How Does it Work?
32
The metal ions in the topical antiperspirant damage the lining of the sweat gland.
As damage continues, a PLUG is formed over the sweat gland.
www.sweathelp.org
Topical TreatmentSweat production never
ceases, the gland is simply plugged
Sweating will return as the skin undergoes regeneration
or shedding
Therefore…topical treatment is NOT a cure!
33Hornberger, 2004
Photo used with permission:Neurosurgical Medical Clinic, Inc
Topical Treatment:How to Use
Best to apply before bedtimeAllow to remain on skin for 6 – 8 hours
Apply every 24 – 48 hours until sweating diminishes
Maintenance applications needed every 1-3 weeks
34
Hornberger, 2004
Topical Treatment: Pros and Cons
35
Non – invasiveItching and burning of skin
at application site&Time-consuming&Temporary reliefHornberger, 2004
Topical Treatment:Effectiveness
36
66.6% stop using dueto the “CONS”
Naumann, Hamm, & Lowe, 2002
88% effective forAxillary Hyperhidrosis
Treatment Options
37
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the second treatmentoption!
Systemic TreatmentAnticholinergics can be used in treating
hyperhidrosisMost effective for cranio-facial hyerhidrosis
Robinul – drug of choice
38
Haider & Solish, 2004
39
Oral Glycopyrrolate (Glycopyrronium bromide)
How Does it Work?
40
Anticholinergic
Blocks Acetylcholine transmission
Eccrine sweat glands no longer stimulated
Sweat production ceases!
Haider & Solish, 2004
Anticholinergics
Long term therapy is requiredMajor side effects:
Dry mouthDry eyes
Constipation Blurred vision
Difficulty with urination
41
Thomas, Brown, & Vafaie, 2004
Anticholinergics
Limited use in treating hyperhidrosis
Only 21% effective
69.7% stop using due to side effects
42
Hamm, Naumann, & Kowalski, 2006
Topical anticholinergics
•glycopyrronium bromide as 1 and 2% cream or roll-on solution
•Topical hyoscine as 0.25, 1, or 3% solution or cream also gave control of sweating, but was associated
with a much higher incidence of side-effects .•Patients with diabetic gustatory sweating have also
noted a reduction in the frequency and severity of episodes after applying glycopyrronium 0.5% cream
43
Treatment Options
44
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the third treatmentoption!
Iontophoresis•Used for palmar and
plantar hyperhidrosis
•Passage of direct electrical current onto skin’s surface
•Device can be purchased for home use
45
Photo used with permission: Beast Psoriasis, 2006
Thomas, Brown, & Vafaie, 200 4
Iontophoresis
Sit with hands or feet in shallow tray of water
Allow 15 – 20 milli-amps of electrical current to pass
through waterUse for 10 days, 30 minutes
each dayMaintenance therapy needed
46
Photo used with permission: Beat Psoriasis, 2006
Thomas, Brown, & Vafaie, 2004
Iontophoresis:Mechanism of Action
47
WATER
+
ELECTRICTY
= Thickening of skinAnd
Blocked sweat flow
www.sweathelp.org
Iontophoresis
Side effects:Skin irritation
Skin burnsVesicle formation
Time consuming treatment
80% effective for palmar and/or plantar hyperidrosis
48
Photo used with permission: Beat Psoriasis, 2006
Thomas, Brown, and Vafaie, 2004
Treatment Options
49
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
50
Botox
Botox injections can be used to treat axillary, palmar, and plantar hyperhidrosis
Analgesic applied prior to injectionNerve block applied to ulnar or radial nerve
prior to palmar injection
51
Haider & Solish, 2004
Botox
52
Botox blocks the release of acetylcholine at the site of the neuromuscular junction.
Sweat glands are not stimulated, and sweat production ceases
Site of blockagePhoto used with permission: Whiteley Clinic, 2007
Haider & Solish, 2004
BIOCHEMICAL PROCESS OF VESCICULAR FUSION BLOCKAGE
53
Botox
Starch Iodine test done prior to injection
Delineates areas of excess sweating with
black-purple discoloration of the skin
54
Photo used with permission: Eisenach, Atkinson, & Fealey, 2005
Haider & Solish, 2004
Botox
Cons:Very painful to the
palms and soles of feetExpensive: $1400-$1600
per treatment
55
Pros: Lasts 6-7 months 90% effective
Thomas, Brown, & Vafaie, 2004
Treatment Options
56
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
Local ExcisionUsed only for axillary hyperhidrosis
Starch Iodine test done prior to excision
Performed under local anesthesia Vasoconstrictor applied to axillary
regionSmall incisions made
57
Eisenach, Atkinson, Foley, 2005
Photo used with permission:Gasparri, 2006
Local Excision
Eccrine sweat glands removed through:Liposuction – suctioned out
Curettage – scraped outExcision – cut out
Incisions suturedPain and bruising to excision site
58
Eisenach, Atkinson, & Fealey, 2005
Photo used with permission:Gasparri, 2006
Local Excision
•Starch Iodine tests done post excision show 80% - 90% decrease in sweating
•Has a potential for scarring
59
Eisenach, Atkinson, & Fealey, 2005
Treatment Options
60
Topical
Systemic
Iontophoresis
Botox
Local Excision
Thorascopic Sympathectomy
Click on the fourth treatmentoption!
Endoscopic Thoracic Sympathectomy (ETS)
Last treatment option
PERMANENT
Surgery performed under general anesthesia
61
Haider & Solish, 2004
ETS
Goal of surgery is to excise or ablate the ganglion that innervate the sweat glands
Performed most frequently for palmar hyperhidrosis
Performed through thorascope or video
Minimally invasive
62
Photo used with permission:Neurosurgical Medical Clinic, Inc
Han, Oren, & Gottfried, 2002
ETS
Small incision made laterally under each axillaIncision made through intercostal space
Surgery can be performed on outpatient basis However, some patients remain in hospital for
one night
63
Han, Oren, & Gottfried, 2002
ETS
Ganglion located along the sympathetic chain
Ganglion formed below each rib
Ganglion can be divided = sympathicotomy
Ganglion can be removed = sympathectomy
64
www.sweathelp.org
Photo used with permission:Neurosurgical Medical Clinic, Inc
ETSGanglion at T2 and T3 = palmar hyperhidrosisGanglion at T3 and T4 = axillary hyperhidrosis
Ganglion at L2-L4 = plantar hyperhidrosis
65
www.sweathelp.org
Photos used with permission:Neurosurgical Medical Clinic, Inc
ETS
Cannot surgically excise or ablate L2-L4 for plantar hyperhidrosis due to sexual side
effects
95% success rate in curing palmar hyperhidrosis
Success rates slightly lower for axillary hyperhidrosis
66
Eisenach, Atkinson, & Fealey, 2005
ETS
Plantar hyperhidrosis resolves in 50% - 75% of cases when T2 and T3 are excised, though L2-
L4 ganglion are never surgically treated
Mechanism is unknown!
67
Eisenach, Atkinson & Fealey, 2005
ETS: Side Effects
Surgical complications:Hemo-pneumothorax requiring chest tube
placement – 1%Atelectasis (collapse of the lung)
Intercostal neuralgia – 1%Horner’s Syndrome – 1%
Compensatory Sweating – 60%
68
Eisenach, Atkinson, & Fealey, 2005
Horner’s Syndrome
Stellate ganglion – fusion of C8 and T1Innervates the face
If Stellate ganglion is damaged, Horner’s Syndrome will occur
May be mistaken for T2 and T3 May receive electrical current from cautery of T2
and T3
69
www.sweathelp.org
Horner’s Syndrome
Signs and SymptomsUnilateral upper eyelid ptosis
Pupil constrictionFacial anhidrosis
70
www.sweathelp.org
Treatment Option Review
71
Hyperhidrosis
Topical Treatment
Botox
Iontophoresis
Local Excision
Iontophoresis
Botox
ETS
AXILLARY PALMOPLANTAR
Hornberger, 2004
Treatment Option Review
72
Photo used with permission: The Whiteley Clinic, 2007
Systemic – blocks acetylcholine
top related