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Treating hyperhidrosis – Letter to the Editor
Excision of axillary tissue may be more effective
EDITOR–We read with interest the editorial on hyperhidrosis by Collin and Whatling. They suggest that botulinum toxin should be the treatment of choice for axillary hyperhidrosis. Early studies have shown that intradermal injection of botulinum toxin produces an effective but temporary inhibition of sweating. The therapeutic effects of botulinum toxin have been reported to last three to eight months in healthy volunteers. There is some evidence to suggest that higher doses of botulinum toxin may produce a satisfactory reduction in sweating for as long as one year in some patients. Continued treatment is inevitable in order to maintain anhidrosis. Repeated injections and hospital visits may be unpleasant and inconvenient for the patient and expensive for the NHS.
Collin and Whatling fail to mention the role of surgical excision of axillary tissue for the treatment of hyperhidrosis. Breach described a simple method of surgical excision of subcutaneous axillary tissue that produced a high satisfaction rate among the reported case group of 25 patients (50 axillae) at follow up after one year. The method described uses three parallel transverse incisions to the axilla, through which the subcutaneous axillary tissue is removed. This technique carries a low complication rate and produces aesthetic scars with negligible functional deficit. Many of the patients attend after thorascopic sympathectomy which resolved their palmar, but not axillary, hyperhidrosis. Surgical excision of axillary tissue remains an important treatment modality for a large proportion of hyperhidrotic patients. It has the ability to provide a permanent and satisfactory solution to a frustrating problem. It is not as yet a redundant method of treatment.
J L Atkins senior house officer, plastic surgery P E M Butler consultant plastic surgeon Royal Free Hospital, London NW3 2QG Collin J, Whatling E Treating hyperhidrosis. BMJ 2000;320:1221-2. (6 May.)  Schnider P, Binder M, Auff E, Kittler H, Berger T, Walsh TN. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. Br J Dermatol 1997;136:548-52.  Naumann M, Flachenecker P, Brocker EB. Botolinum toxin for palmar hyperhidrosis. Lancet 1997;349:252.  Heckmann M. Follow up of patients with axillary hyperhidrosis alter botulinum toxin injection. Arch Dermatol 1998;134:1298-9.  Breach NM. Axillary hyperhidrosis: surgical cure with aesthetic scars. Ann R Coll Surg Engl 1979;61:295-7.
Iontophoresis should be tried before other treatments
EDITOR–We read with interest the editorial by Collin and Whatling about the treatment options for hyperhidrosis. Hyperhidrosis is a socially debilitating, and patients with the condition often do not do well with topical treatment with aluminium chloride hexahydrate or anticholinergic drugs.
Dermatologists are often presented with this problem. Most patients have the hyperhidrosis localised to their hands and feet. Although thoracoscopic sympathectic trunkotomy and botulinum toxin injections may be effective, they can produce serious side effects, some of which may be irreversible. Dermatology centres offer a further treatment option.
Iontophoresis is easy to perform, effective in about 90% of patients in two studies with 54 and 30 participants, free of hazardous side effects, and well accepted by almost all patients.[2 3] Contraindications to treatment are pregnancy, cardiac pacemakers, and metal orthopaedic implants. Almost complete cessation of sweating occurs after four treatments of about 10 minutes over two to three weeks. The machines cost considerably less than 1000 [pounds sterling], and, since tap water is used to conduct the electric current, this is a cheap alternative treatment compared with botulinum toxin or surgery. This should primarily be offered to patients with palmarplantar hyperhidrosis, whereas the more aggressive treatments should be reserved for those who do not respond or have axillary problems that are less amenable to treatment with iontophoresis.
Patients presenting with palmar-plantar hidrosis deserve a trial of all conservative treatments including iontophoresis before more aggressive techniques such as botulinum toxin or thorascopic sympathetic trunkotomy are tried.
R Murphy specialist registrar dermatology C I Harrington consultant dermatologist Royal Hallamshire Hospital, Sheffield S10 2JF Collin J, Whatling E Treating hyperhidrosis. BMJ 2000;320:1221-2. (6 May.)  Odia S, Vocks E, Rakoski J, Ring J. Successful treatment of dyshidrotic hand eczema using tap water iontophoresis with pulsed direct current. Acta Derm Venereol 1996;76:472-4.  Reinauer S, Neusser A, Schauf G, Holzle E. Pulsed direct current iontophoresis as a possible new treatment for hyperhidrosis. Hautarzt 1995;46:543-7
Anticholinergic drugs were not mentioned
EDITOR–We disagree with the subtitle of the editorial by Collin and Whatling–namely, that surgery and botulinum toxin are treatments of choice in severe cases of hyperhidrosis. They dismiss conventional medical treatment with anticholinergic drugs as inconvenient, unpleasant, and temporary, and they say that 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 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 with anticholinergic drugs. We have used glycopyrronium bromide (Robinul), 2 mg up to three times daily, for 25 years with great success. Most patients we see are young women, whose hyperhidrosis is ruining their lives. This drug greatly improves their quality of life, and the inevitable dry mouth is accepted unreservedly.
Young women do not suffer any other unwanted effects, although 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 United Kingdom and licensed as an antispasmodic; it was quite inexpensive. Now it is available only from the United States, on a named patient basis, and the importer has recently doubled the price to 72 [pounds sterling] for 100 x 2 mg. Patients believe that it is worth every penny, but perhaps some enterprising British drug manufacturer would care to manufacture it again.
Michael Klaber consultant dermatologist Broomfield Hospital, Chelmsford CM1 7ET F.Spoor@icrf.icnet.cuk
Michael Catterall consultant dermatologist Basildon Hospital, Basildon SS16 5NL Collin J, Whatling E Treating hyperhidrosis. BMJ 2000;320:1221-2. (6 May.)
Treatment options must be balanced against each other
EDITOR–Someone not familiar with managing hyperhidrosis would think that the matter was all cut and dried after reading the editorial by Collin and Whatling. The authors are surgeons and are drawing on their experience of the patients referred to them from various colleagues who consider these patients possible candidates for surgery. This may be because these patients report that medical treatments are inconvenient, temporary, and unpleasant. But the topic is far broader than these selected patients.
There is a definite role for topical and systemic medication in a range of patients. These treatments are less absolute in their outcomes and also less permanent. They do, however, not produce compensatory sweating. For treatment of upper limb hyperhidrosis, compensatory sweating is commonly reported to occur in 50-70% of patients, with a figure of 97% in one series of 91 patients. The feet and trunk are the main affected sites.
A further aspect is gustatory sweating, which amounts to an outbreak of sweating on the smell or taste of food, reported in 50.7% of subjects in one series of 323 patients. This does not equate with treatment failure, but should be emphasised before the operation. Collin and Whatling report an initial cure of 100%, and it seems that this is maintained to a great extent for palmar hyperhidrosis. The results are less rewarding for axillary hyperhidrosis, however, where satisfaction rates after one year are as low as 33.3% in comparison with 66.7% for palmar sweating.
Surgery is a valuable option in this troublesome condition, but we should present a balanced picture of its virtues and not dismiss less aggressive forms of treatment.
David de Berker consultant dermatologist Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol BS2 8HW Collin J, Whatling P. Treating hyperhidrosis. BMJ 2000;320:1221-2. (6 May.)  Chiou TS, Chen SC. Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis. Br J Surg 1999;86:45-7.  Herbst F, Plas EG, Fogger R, Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations. Am Surg 1994;220:86-90.
EDITOR–Successful removal of axillary tissue through three parallel transverse incisions, as suggested by Atkins and Butler, certainly cures axillary hyperhidrosis. The complications are wound infection, abcess formation, skin necrosis, cutaneous anaesthesia, scarring, keloid formation, and limitation of shoulder abduction.
Iontophoresis, as suggested by Murphy and Harrington, stops sweating by waterlogging the skin to block the sweat ducts. The same effect is produced by prolonged immersion in water. Ten minutes of iontophoresis in hospital involves expensive equipment, hours of commuting and waiting time, inconvenience, and travel costs. Immersion of hands and feet in bowls of warm water at home is cheaper, quicker, and more convenient and has no contraindications.
Anticholinergic drugs, as recommended by Klaber and Catterall, reduce sweating and provide some relief from hyperhidrosis. Their unwanted effects include reduced salivation with a dry mouth and impaired speech, taste, mastication, and swallowing; a dilated pupil, photophobia, blurred vision, and acute glaucoma; impaired micturition, reduced bronchial secretions, and constipation; confusion, nausea, vomiting, and giddiness; tachycardia, palpitations, and arrythmias. Nine months’ supply of glycopyrronium bromide costs 592 [pounds sterling] ($905), excluding physician and dispensing fees, compared with 165 [pounds sterling] ($252) for bilateral axillary injection of botulinum toxin.
The total lifetime cost of unilateral thoracoscopic sympathectomy is 1913 [pounds sterling] ($2927). Thoracoscopic sympathectomy performed as a separate operation on each side has slight risks of serious complications or death. The incidence and severity of compensatory hyperhidrosis increase with the area of skin sympathetically denervated. Unilateral sympathetic trunkotomy between the T1 and T2 ganglia guarantees a dry handshake and solves the problem for many patients. It is rarely followed by compensatory hyperhidrosis. Bilateral trunkotomy often induces compensatory hyperhidrosis, but it is seldom troublesome. To cure axillary hyperhidrosis, T2 and T3 sympathetic ganglionectomy is necessary; after bilateral surgery compensatory hyperhidrosis is usual and sometimes bothersome. Pathological gustatory sweating is an uncommon complication of thoracic sympathectomy. Its high reported incidence in some series may be attributable to diathermy injury to the T1 sympathetic ganglion.
For disabling palmar hyperhidrosis, thoracoscopic sympathetic trunkotomy is the treatment of choice. Axillary hyperhidrosis is cured for around nine months by injection of botulinum toxin. Lumbar sympathectomy has no place in the treatment of pedal hyperhidrosis since ejaculatory impotence and anorgasmia are likely consequences. Pedal botulinum toxin injection is unacceptable to most patients and some doctors. The palliation provided by anticholinergic drugs, iontophoresis, and aluminium chloride hexahydrate is balanced by their expense, inconvenience, and unwanted pharmacological effects.
Jack Collin consultant surgeon Nuffield Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU
COPYRIGHT 2000 British Medical Association
J L Atkins, P E M Butler, R Murphy, C I Harrington, Michael Klaber, Michael Catterall, David de Berker, Jack Collin