Treating hyperhidrosis
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7244.1221 (Published 06 May 2000) Cite this as: BMJ 2000;320:1221All rapid responses
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Sir - I read with interest the editorial article "Treating
hyperhidrosis" by Collin J and Whatling P.1 We are happy to know that
they have confirmed the efficacy and superiority of the video
thoracoscopic sympathectomy in treating palmar hyperhidrosis (PH), which
we first developed in 1990. Subsequently, it was proven to be simple and
effective and has been widely accepted as a standard treatment of PH.2,3,4
PH is a common disorder in Orientals from subtropical areas. Approximately
0.35% of the population in Taiwan have PH and of these, as high as 12.5%
of their families have PH.2,3,4
We agree that axillary hyperhidrosis is often not cured by
sympathectomy, but can be alleviated by T2 and T3 sympathectomy, which is
however quite easy and simple via thoracoscopic approach. 3,4
We advocate segmental electrocoagulation of the target sympathetic
trunk over the underlying bony rib head rather than excision of the entire
trunk which is time-consuming and has a high risk of injuring costal
vessels and nerve.3,4
Based on our experience in using intraoperative monitoring of palmar
skin temperature to confirm an adequate extent of sympathectomy, simple
division of the trunk with scissors on the 2nd rib often does not ensure a
long-lasting therapeutic effect.3,4
With our technique, no intercostal neuralgia was encountered, and
postsympathectomy gustatory sweating was very rare in our series.5
Ming-Chien Kao, M.D. D.M. Sc.
Professor and chief,
Division of Neurosurgery,
National Taiwan University Hospital
President,
Taiwan Neurosurgical Society,
No. 7, Chung-Shan S. Rd,
Taipei, Taiwan 100, ROC
References:
1. Collin J., Whatling P. Treating hyperhidrosis: Surgery and botulinum
toxin are treatment of choice in severe cases. BMJ, 2000; 320:1221-1222.
2. Kao MC, Lee WY, Yip KM, Hsiao YY, Lee YS, Tsai JC. Palmar
hyperhidrosis in children: Treatment with video endoscopic laser
sympathectomy. J. Pediat. Surg. 1994; 29: 387-391.
3. Kao MC, Tsai JC, Lai DM, Hsiao YY, Chiu MJ. Autonomic activities
in hyperhidrosis patients before, during, and after endoscopic laser
sympathectomy. Neurosurg. 1994; 34 (2): 262-268.
4. Kao MC, Lin JY, Chen YL, Hsieh CS, Cheng LCJ, Huang SJ. Mininally
invasive surgery: video endoscopic thoracic sympathectomy for palmar
hyperhidrosis. Ann Acad Med Singapore. 1996; 25: 673-678.
5. Kao MC. Correspondence: Complications in patients with palmar
hyperhidrosis treated with transthoracic endoscopic sympathectomy.
Neurosurg. 1998; 42: 951-952.
Competing interests: No competing interests
Editor
I agree with Klaber and Catterall the title and subtitle of our
leading article are misleading. The title of our paper as submitted was
"The Treatment of Idiopathic Palmar, Axillary and Plantar
Hyperhidrosis."We have made no claim for the use of sympathectomy or
botulinum toxin in the treatment of sweating from other sites.
In my view Thoracoscopic sympathetic trunkotomy is the treatment of
choice for patients with disabling hyperhidrosis confined exclusively or
predominantly to the hands. In such patients operation on the right side
solves the problem for many with a negligible risk of compensatory
hyperhidrosis. For those who subsequently elect to have the left side done
the modest risk of compensatory hyperhidrosis has to be balanced against
the benefits of a dry left hand.
For patients with palmar and axillary hyperhidrosis the axillary
component can be abolished if the 2nd and 3rd sympathetic ganglia are
ablated. The disadvantage of bilateral T2 and T3 ganglionectomy is a high
risk of distressing compensatory hyperhidrosis. Combining unilateral or
bilateral sympathetic trunkotomy with bilateral axillary botulinum toxin
injections is an alternative choice.
Sympathectomy is not appropriate for the treatment of axillary
hyperhidrosis in patients who do not also have palmar
hyperhidrosis.Axillary hyperhidrosis is easily relieved for around 9
months by botulinum toxin injections. Patients confirm it`s success by
their requests for repeated treatments.
Impotence is not a risk of thoracic sympathectomy.Bilateral lumbar
sympathectomy is likely to cause ejaculatory failure in men and since the
innervation is similar probably orgasmic failure in women.Consequently
lumbar sympathectomy has no role in treating pedal hyperhidrosis. A few
patients with severe sweating of the feet unresponsive to other therapy
may opt for pedal botulinum toxin injections even when they are advised
that the treatment is uncomfortable and has a relatively short duration of
effectiveness.
Competing interests: No competing interests
We would strongly disagree with the subtitle of this editorial (6 May
2000)-"Surgery and botulinum toxin are treatments of choice in severe
cases."
Collin and Whatling dismiss conventional medical therapy with
anticholinergic drugs as "inconvenient, unpleasant and temporary. Patients
usually stop using anticholinergic drugs because of a dry mouth."
The truth is exactly the opposite. Surgery is only rarely necessary
and the editorial quite properly warns of numerous surgical pitfalls which
include recurrence of hyperhidrosis, almost certain impotence,
compensatory sweating, permanent neurological damage from anoxia and death
(their words). Botulinum toxin, which they recommend for axillary or
plantar hyperhidrosis, requires 12 injections per axilla and "tedious and
uncomfortable 24-36 injections per foot." Even this horrendous procedure
gives only 11 months relief and antibody formation may reduce long term
efficiency.
The logical treatment is surely with anticholinergic drugs. We have used
Glycopyrronium bromide (Robinul) 2mgs up to three times daily for 25 years
with great success. The majority of patients we see are young women, whose
hyperhidrosis is ruining their lives. Robinul greatly improves their
quality of life and the inevitable dry mouth is accepted unreservedly.
Young women do not suffer any other unwanted effects, though it is obvious
that older men (who do not as a rule present to us with hyperhidrosis) may
well have problems with vision and micturition. The North East Thames
Regional Drug Information Service could find no evidence of any long term
side effects; some patients have used it for years.
The sting is in the tail. The drug was manufactured in the UK and licensed
as an antispasmodic; it was quite inexpensive. Now it is only available
from the USA on a named-patient basis and the importer has recently
doubled
the price to £72 for 100 x 2mgs. Patients feel that it is worth every
penny, but perhaps some enterprising UK drug manufacturer would care to
manufacture it again.
Michael Klaber
Consultant Dermatologist and Hon Senior Lecturer.
Broomfield Hospital, Chelmsford, CM1 7ET
Michael Catterall
Consultant Dermatologist
Basildon Hospital, Basildon, SS16 5NL
Competing interests: No competing interests
Editor
Cameron`s claim that there has been only one death attributable to
synchronous bilateral thoracoscopic sympathectomy is implausible. Surgeons
and anaesthetists are reticent in publicizing such events and Civil Law
Reports of settled cases are an inadequate measure of the current running
total. The custom of a majority is no guarantee of safety and is seldom a
guide to best medical practice.
Competing interests: No competing interests
Jack Collin should be able to do better than simply restate his
position on bilateral sympathectomy and thereby assume we will all now
agree.
He provides no new evidence. Indeed he concedes my point that worldwide
opinion favours a synchronous approach. The one death in many thousands of
operations was due to inexperience.
His desire for "safety" is simply a reflection of the small numbers he has
treated.
Competing interests: No competing interests
SIR - We read with interest the editorial 6th May about the treatment
options for hyperhidrosis. As the authors point out hyperhidrosis is a
socially debilitating and patients with the condition often do not do well
with topical aluminium chloride hexahydrate or anticholinergic drug
treatment. Dermatologists are also not infrequently referred this problem.
In our experience most patients have the hyperhidrosis localised to their
hands and feet. As the authors discuss, whilst thoracoscopic sympathectic
trunkotomy and botulinum toxin injections may be effective, they can
produce, serious side effects some of which may be irreversible. There is
how treatment option, in dermatology centres . It is easy to perform,
effective in more than 90% of patients, free of hazardous side-effects and
well accepted by almost all patients 1,2. The only contraindications to
treatment are pregnancy, cardiac pacemakers and metal orthopaedic
implants. Almost complete cessation of sweating occurs after 4 treatments
of approximately 10 minutes duration per treatment over a 2-3 week period.
The machines cost considerably less than £1000 and since tap water is used
to conduct the electric current, this is a cheap alternative treatment
when compared to botulinum toxin or surgery. This should primarily be
offered to patients with palmarplantar hyperhidrosis with the more
aggressive therapies reserved for those failing to respond or with
axillary problems which are less amenable to treatment with iontophoresis.
We feel that patients presenting with palmarplantar hidrosis deserve a
trial of all conservative therapies including iontophoresis before more
agressive techniques such as botulinum toxin or thorascopic sympathetic
trunkotomy are tried.
R.Murphy
SpR Dermatology
C.I Harrington
Consultant Dermatologist
References
1 Heckmann M, Schaller M, Plewig G et al. .Optomizing botulinum toxin
therapy for hyperhidrosis. Br J Dermatol 1998; 138: 553-554.
Competing interests: No competing interests
Editor- Cameron may not advocate that bilateral thoracoscopic
sympathectomy should be staged but I certainly do .It may be eccentric but
it is safe.Immediate sustained full reexpansion and perfect functioning of
a lung that was completely deflated a few minutes before cannot be
guaranteed. Residual pneumothorax is common,gas exchange may be impaired
and the lung is at some risk of recollapse.To collapse the contralateral
normal lung in such circumstances might be the practice of a majority of
surgeons but it is still unwise.Collapse of one lung is a misfortune,
collapse of both lungs is not compatible with life.
Competing interests: No competing interests
Editor - In their discussion of endoscopic sympathectomy Collin and
Whatling1 misquote me. I do not advocate two separate operations, only
that care must be taken to wait for a few minutes between the two sides.
As I have written elsewhere "The only reason for embarking on a unilateral
operation is surgical or anaesthetic inexperience".2
Their article is based on the senior author's series of fifty four cases
all of which required two sessions. This study contained only half the
patients reported on ten years ago by Hederman's group3 and is very small
when compared with the large series from Brazil, Sweden, Taiwan and
Israel.
Worldwide opinion favours the synchronous bilateral approach and I am
disturbed to find that the Oxford group appear to be enlisting my support
for their eccentric unilateral technique.
Alan Cameron, M.Ch., F.R.C.S.
Consultant Surgeon
The Ipswich Hospital,
Heath Road,
Ipswich,
Suffolk
IP4 5PD
1 Collin J, Whatling P. Treating hyperhidrosis. BMJ
2000;320:1221-2(6 May)
2 Cameron AEP. Early experience with day-case transthoracic
endoscopic sympathectomy[Letter.] Br J Surg 1999;86:139
3 Byrne J, Walsh TN, Hederman WP. Endoscopic transthoracic
electrocautery of the sympathetic chain for palmar and axillary
hyperhidrosis. BrJSurg 1990;77:1046-9
Competing interests: No competing interests
Editor
de Berker draws attention to the high reported rates of
compensatory hyperhidrosis after thoracoscopic sympathectomy but overlooks
the explanation given in our edtorial. The incidence and severity of
compensatory hyperhidrosis is proportunal to the surface area rendered
anhidrotic.Unilateral division of the sympathetic trunk between the first
and second sympathetic ganglia,all that is required to stop sweating in
one hand,has in our experience never been followed by troublesome
compensatory or gustatory sweating.After bilateral sympathetic trunkotomy
compensatory sweating is uncommon but after bilateral T2,T3 ganglionectomy
it is common and frequently troublesome.We do not recommend sympathectomy
for patients with only axillary hyperhidrosis and we believe that in these
patients botulinum toxin injection is the treatment of choice.For patients
with both palmar and axillary hyperhidrosis the options are [1]sympathetic
trunkotomy plus axillary botulinum toxin injection or [2]T2,T3
ganglionectomy if they are prepared to accept the risk of troublesome
compensatory sweating.
Competing interests: No competing interests
Re: Treating hyperhidrosis
We read with interest the debate in the BMJ about treating
hyperhidrosis.
Sympathectomy is often the last resort for those patients who suffer from
hyperhidrosis, almost all of whom have seen their own GPs and/or
dermatologists and have tried all the topical commercial remedies without
long lasting benefit. Botulinum toxin with its attendant tedious way of
application, although effective, only lasts for a few months. In their
editorial, Jack Collins and Paul Whatling have mentioned death and
permanent neurological anoxic damage from the “unwisely performed”
bilateral thoracic sympathectomy for treating hyperhidrosis(1). They also
mentioned Horner’s syndrome as a complication of deliberate or inadvertent
damage to the first thoracic ganglion, and they therefore recommend a
staged procedure.
From November 1994 until now we have performed 146 thoracoscopic
sympathectomy operations. We routinely perform a bilateral sympathectomy
whenever possible. Our dedicated thoracic anaesthetists who are well
experienced in one lung anaesthesia and jet ventilation, allow for this
procedure to be carried out safely and efficiently. To date we have had no
deaths, permanent neurological anoxic damage or any other major
complication (2). Horner’s syndrome, although a recognizable complication,
has not been reported in any of our patients. Only in situations where one
lung anaesthesia is not tolerated, most commonly in chronic heavy
cigarette smokers with emphysematous lungs, or in a few other occasions
such as cases in which anatomical difficulties or extensive adhesions of
the lung are encountered do we perform a unilateral sympathectomy.The key
to minimizing anaesthetic complications is to partially collapse the lung
by using either positive end expiratory pressure on the side being
operated on, or bilateral jet ventilation.
We agree with Cameron (3), that bilateral sympathectomy should be the
rule rather than the exception and we strongly recommend routine bilateral
sympathectomy when a back up of experienced anaesthetists and theatre
equipment is available. In this way patients can be saved an unnecessary
second admission, second general anaesthetic and surgical operation and an
increased overall cost is avoided.
Alsir Ahmed*, FRCS, Specialist Registrar
James McGuigan, FRCS, Consultant thoracic surgeon
Regional thoracic surgery department,
The Royal Victoria hospital,
Belfast, Northern Ireland.
* Corresponding author,
e-mail: alsir@hotmail.com
References:
1-Collin J, Whatling P. Treating hyperhidrosis. BMJ 2000; 320: 1221-
1222. (6 May).
2- Graham ANJ,Owens WA, McGuigan JA. Assessment of outcome after
thoracoscopic sympathectomy for hyperhidrosis in a specialised unit.
J R
Coll Surg Edinb. 1996 June; 41(3): 160-163.
3- Cameron A. Treating hyperhidrosis. BMJ 2000 (17 May).
Competing interests: No competing interests