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Excessive seating from the armpits can be very debilitating causing a bad odor, staining of clothing and restriction of social as well as exercise related activities. This problem can also affect the palms of the hands or soles of the feet.
Sweat glands maintain skin surface health and regulate body temperature by supplying water to the skin surfaces for evaporation. Two types of sweat glands are present over human skin, eccrine and apocrine glands. Millions of eccrine glands are distributed throughout the entire body surface and produce a high salt content sweat that is excreted directly onto the skin through an excretory duct. The greatest density of these glands is found in the armpit, palm, and sole of the foot. The apocrine sweat glands are less in number and are distributed over the armpits, around the anus, around the breast nipple complex, and eyebrow regions. In addition to salt, the sweat from these glands contains fat and cholesterol and is excreted indirectly by passing through the shaft of hair follicles. The apocrine gland is 10 times larger than the eccrine gland, and both are present in equal numbers in the armpits. The apocrine glands start secreting at puberty and stop after menopause in women. Overproduction of either gland in the presence of certain skin surface bacteria can produce a bad odor. Clogging of the apocrine glands leads to a condition called hydradenitis suppuritiva with abscesses and draining pus. The treatment for this is surgical removal of the glands together with the damaged skin and then surgical closure of the resulting wound.
The treatment of excessive sweating (hyperhidrosis) alone is more straight forward though a number of treatment modalities have been used to reduce the volume of sweat produced. However no single treatment is without its weakness or complications.
A hyperhidrosis diagnosis is made in patients who have visible, excessive sweating for at least 6 months without apparent cause, and with at least two of the following characteristics:
• Impairs daily activities.
• Frequency of at least one episode per week.
• Bilateral and symmetric.
• Age of onset before 25 years.
• Positive family history.
• Cessation during sleep.
Excessive sweating is graded according to severity:
1-My sweating is never noticeable and never interferes with my daily activities.
2-My sweating is tolerable but sometimes interferes with my daily activities.
3-My sweating is barely tolerable and frequently interferes with my daily activities.
4-My sweating is intolerable and always interferes with my daily activities.
7.6 million, 4% of the population, in the US have level 3 or 4 axillary hyperhidrosis.
- non-surgical treatments produce acceptable results with minimal risks but are not permanent
- topical antiperspirants and deodorants Agents applied to the skin achieve their effect either by blocking the excretory ducts of the eccrine glands or are astringent, acting on the sweat glands and the skin surface. A commonly used effective antiperspirant is aluminum chloride hexahydrate. Drawbacks to this treatment include its short-lived effect, with continued success depending on daily application. Skin irritation is a potential complication of treatment and may be intolerable.
- oral medications Anticholinergic medications, such as glycopyrronium bromide and propantheline bromide, can be used but have a number of unpleasant side effects that limit their usefulness. Common side effects of these drugs include a dry mouth, blurred vision, urinary retention, and constipation, and generally exclude long term use.
- botox injections into the armpits or palms Botox is particularly useful in the treatment of focal areas of excessive sweating. Multiple injections spaced 1 to 2.5 cm apart into the affected area are required. The duration of the therapeutic effect of botulinum toxin varies depending on each individual and the dose given, with a return of sweating reported after a gap of between 3 and 8 months. Reports of continued adequate control of sweating at 1-year have been reported using a higher dose, with 500 units of botulinum toxin being injected into each armpit. Weakness of the small muscles of the hand can be a problem in the treatment of palm sweating, leading to a weaker grip. The major drawback to this treatment is the discomfort associated with the use of multiple injections particularly in the treatment of the palms of the hand and soles of the feet.
- microwave thermolysis system, MiraDry Microwave energy is absorbed by electric dipoles i.e. the charged ions (sodium, potassium...) contained in sweat. Combined with skin surface cooling this concentrates heat at the level of the sweat glands to kill them. Treatments are performed under local anesthesia and last about 30 minutes. About 90% of patients respond to 2 treatments whose effects last about 12 months. Reported side effects are temporary swelling and transient altered skin sensation.
- surgical treatments are a valuable option for treatment but because of a number of potential complications, surgery should be reserved for only the more aggressive forms of the disease that remain unresponsive to non-surgical treatment.
- endoscopic transthoracic sympathectomy or Thoracoscopic sympathectomy. Sympathetic nerve fibers in the upper back chest cavity supply the eccrine glands of the palm and armpit. Cutting these nerves stops sweating mostly in the palms and to a lesser extent in the armpit. Historically this was done by cutting into the chest which necessitated a long recovery time with greater risk of complications. Currently this can be done using a scope inserted through a small hole between the ribs. Patients can usually return to normal activity within a few days after the operation. The condition may return if the nerve is incompletely divided, anatomic landmarks are incorrectly identified, or nerve regeneration occurs. It is an invasive procedure even though less so using the scope and therefore the risk of injury to deeper structures is a possibility. Side effects of the sympathectomy itself include compensatory sweating (excessive sweating on the trunk, limbs, or face or sweating while eating) that can affect as many as 50 percent of patients, and is more common in patients having both right and left sympathectomies. Therefore it may be wise to do only one side. Permanent nonfunction of the eccrine glands after sympathectomy can lead to skin overgrowth, scaling, and fissuring.
- direct removal of the sweat glands by liposuction Liposuction close to the undersurface of the skin almost scraping it has been described. The success of the technique may partly be because of disruption of the nerve supply to the sweat glands and removal or destruction of the apocrine glands that are present in the axilla in high density. The true efficacy of this treatment has not been established.
- direct removal of the sweat glands by surgical excision This involves removal of skin and/or underlying tissue. It is currently my preferred technique as it has the best mix of effectiveness, reliability and low complication rate when only the glands are removed leaving intact skin. Three parallel transverse incisions 1.5 cm in length and .75cm apart are made across the armpit. The skin between the incisions is flipped and the glands underneath removed directly. Small drains are left in place for 3 to 5 days to prevent any blood from collecting underneath. There is no hand raising for 10days and the sutures are removed about 12 days after surgery.
- laser destruction of the eccrine sweat glands This procedure is performed much like liposuction but a laser probe is inserted instead of a liposuction cannula. The laser is pointed at the undersurface of the skin and kills the sweat glands. The efficacy of this method has proven to be equal to direct removal by surgery but it is unclear if it offers any advantage (such as quicker recovery or more complete resolution of the problem) besides being a laser.
In the absence of infection or skin damage the only problem are the glands themselves so removal of armpit skin seems excessive and has a propensity to leave bad scars.
The EU CE approval was just given for MiraDry in treating hyperhydrosis. It was approved for use in the US by the FDA in January 2011.
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter