http://www.cmaj.ca/cgi/content/full/172/1/69

 Dripping Silver
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(1/13/05 12:09 am)
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 Article~Canadian Medical Jnl & Reply Letter From Taiwan
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 Link To Abstract in Canadian Medical Journal

CMAJ  January 4, 2005; 172 (1). doi:10.1503/cmaj.1040708.
 2005 Canadian Medical Association or its licensors
This Article 

Abstract 

PubMed Citation 
Articles by Haider, A. 
Articles by Solish, N. 

Review
Synthse 

Focal hyperhidrosis: diagnosis and management 
Aamir Haider and Nowell Solish 
From the Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ont. 

CLICK ON THE LINK TO READ THE FULL ARTICLE--HERE ARE ONLY A FEW OF THE PARAGRAPHS

HYPERHIDROSIS, A CONDITION CHARACTERIZED by excessive sweating, can be generalized or focal. Generalized hyperhidrosis involves the entire body and is usually part of an underlying condition, most often an infectious, endocrine or neurologic disorder. Focal hyperhidrosis is idiopathic, occurring in otherwise healthy people. It affects 1 or more body areas, most often the palms, armpits, soles or face. Almost 3% of the general population, largely people aged between 25 and 64 years, experience hyperhidrosis..................

Pathophysiology

The pathophysiology of focal hyperhidrosis is poorly understood. Sweat is produced by the body's sweat glands: there are up to 4 million sweat glands, of which about 3 million are eccrine sweat glands and the remainder are apocrine glands.7 Eccrine sweat glands are innervated by cholinergic fibres from the sympathetic nervous system. Their primary function is the secretion of sweat  an odourless, clear fluid that regulates body temperature  the rate of which is affected by emotional and gustatory stimuli. Eccrine sweat glands, which are responsible for focal hyperhidrosis, are distributed over nearly the entire body surface, although their density is highest in the soles of the feet and the forehead, followed by the palms and cheeks. Apocrine sweat glands are scent glands and are primarily confined to the axillary and urogenital regions. They are not involved in focal hyperhidrosis, and their function is regulated by hormonal processes. There are also mixed sweat glands called apoeccrine glands, which are primarily found in axillary and perianal areas. Their role in the pathophysiology of focal hyperhidrosis is unknown, although in some patients they constitute up to 45% of the sweat glands found in the axillary region.8 

No histopathological changes in the sweat glands have been observed in patients with focal hyperhidrosis, nor do these patients have increased numbers of or larger sweat glands.7Rather, focal hyperhidrosis may represent a complex dysfunction of the autonomic nervous system, involving both the sympathetic and parasympathetic pathways. A genetic predisposition may exist, since 30%50% of patients have a family history of hyperhidrosis.9 In a study by Shih and colleagues,10 patients with palmoplantar hyperhidrosis showed less reflex bradycardia in response to Valsalva's manoeuvre and a higher degree of vasoconstriction in response to finger immersion in cold water. Such an increased sympathetic activity through the T2T3 ganglia could cause palmar hyperhidrosis. Excessive palmar and plantar sweating could thus result in a vicious cycle, as evaporative cooling of the skin increases sympathetic outflow through reflex action, which in turn increases sweat output. Parasympathetic dysfunction was implicated in a study that compared heart rate variability in patients with focal hyperhidrosis with that of healthy control subjects.11 The authors found that, although sympathetic activity seemed to be similar, patients with focal hyperhidrosis exhibited heart rate patterns suggesting parasympathetic dysfunction. .......................

Surgical treatments

Surgical treatments include endoscopic thoracic sympathectomy, which destroys the sympathetic ganglia by excision, clamping, transection or ablation with cautery or laser. Several retrospective studies and uncontrolled clinical trials have demonstrated that endoscopic thoracic sympathectomy is effective in eliminating axillary, palmar and facial hyperhidrosis in 68%100% of cases.5,23,24,25 Plantar hyperhidrosis was reduced in 58%85% of patients. The main limitation of this procedure is a high incidence of mild to severe compensatory hyperhidrosis, usually involving the trunk and lower limbs, in up to 86% of patients.34 Other adverse effects include gustatory sweating, phantom sweating (the sensation of impending hyperhidrosis in the absence of sweating), neuralgia, Horner's syndrome and the risk of hemothorax or pneumothorax.34 Furthermore, lumbar sympathectomy for plantar hyperhidrosis is associated with sexual dysfunction.13 Other surgical procedures with reported efficacy include excision of axillary tissue and subcutaneous axillary curettage and liposuction.26,38,39 Surgical options for focal hyperhidrosis are associated with high efficacy rates, but they should be reserved for patients for whom other treatments have been ineffective and who appreciate the risks associated with the procedure and potential complications...................................


Conclusion

Various treatments of focal hyperhidrosis are available. Aluminum chloride-based topical treatments can be used as first-line treatment of axillary hyperhidrosis, which is the most frequent form of focal hyperhidrosis, as well as of palmar hyperhidrosis. Iontophoresis can be used as second-line treatment of palmar and plantar hyperhidrosis. Botulinum toxin seems the most effective treatment, but it is painful and costly. Surgical thoracic sympathectomy may be the only solution for patients with severe hyperhidrosis in whom other treatments have not produced satisfactory results. The role of alternative and systemic treatments in focal hyperhidrosis remains to be established. Given that effective treatment can result in dramatic improvements to a patient's quality of life, physicians can play an instrumental role in the diagnosis and management of this distressing condition

AND THE PUBLISHED REPLY LETTER TO THE ABOVE ARTICLE:
Min-Huei Hsu 
Department of Neurourgery, Taipei City Hospital, Zhongxiao Branch 
Endoscopic thoracic sympathectomy is prohibited for patients under 20 years old in Taiwan 10 January 2005 

Endoscopic thoracic sympathectomy (ETS) has come into widespread use for palmar hyperhidrosis. Side sffects after ETS was widely discussed in Taiwan society in the past few months. Lots of people in Taiwan suffer from hyperhidrosis palmaris. ETS is covered by the National Health Insurance, and patient billing for this operation does not exceed US$ 60. This is why this operation is so popular here 1 . 

Patients with severe compensatory sweating after ETS must change clothes several times a day (some patients complained that they change as often as 10 times a day), resulting in serious impact on work and social interaction. Patients suffering from such serious side effects in Taiwan have formed a support group based on an Internet discussion forum to request the government to take this problem seriously. Starting in October 2004, The Department of Health, Executive Yuan, Taiwan, has prohibited surgeons from performing this operation on patients under 20 years old. To our knowledge, this type of support group also exists in United States, England, Sweden, Spain and Japan (Table 1). 

ETS is a relatively safe and simple procedure. However the side effects are possibly devastating 2 . All physicians providing this service and all peoples preparing to undergo this treatment should know this well. 


Table 1: Websites built by suffers of side effects after ETS 

ETS And Reversals Discussion Forum 
http://pub157.ezboard.com/betsandreversals 
United States (English) 

World Against Sympathectomy 
http://www.truthaboutets.com/ 
United States (English) 

The Sympathetic Association 
http://home.swipnet.se/sympatiska/index3.htm 
Sweden (English) 

Against Sympathetic Surgery 
http://www.ets-sideeffects.netfirms.com/ 
Australia (English) 

Radisson Group 
http://www.noetsuk.com/ 
Britain and Ireland (English) 

Family of Compensatory Sweating Sufferers 
http://home.pchome.com.tw/family/vivi12175/ 
Taiwan (Chinese) 

ETS Side Effects 
http://www.geocities.jp/etscontroversialop/index.html 
Japan (Japanese) 

Hyperhidrosis Forum 
http://www.terra.es/personal8/hiperhidrosis/principal.htm 
Spain (Spanish) 


Min-Huei Hsu, M.D. 
Department of Neurourgery , Taipei City Hospital, Zhongxiao Branch 
Taipei, Taiwan 

Ju-Chuan Yen M.D. 
Department of Ophthalmology , Taipei City Hospital, Zhongxiao Branch 
Taipei, Taiwan 

Yu-Chuan Li, M.D., Ph.D. 
Graduate Institute of Medical Informatics , Taipei Medical University 
Taipei, Taiwan 


















Edited by: Dripping Silver at: 1/13/05 12:14 am
 
csmess
Local user
Posts: 393
(1/13/05 11:51 am)
Reply  Re: Article~Canadian Medical Jnl & Reply Letter From Tai
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 Am I reading this correctly? Was that reply letter sent and signed by three, licensed medical doctors?!?!

If so, all I can say is Bravo! Bravo! This is a fantastic development. This is something we really need...physicians bravely standing up for the patients who have come to them with disabling side effects from ETS.

The only other time this has happened is when a doctor from New York challenged the surgeons on their own forum after ETS victims came to his office with horrible side effects.

I would like to get the email addresses of these three doctors and send them a thank you note. We all should do that.  
