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Hyperhidrosis (Excessive Sweating)Everybody sweats! So what’s the problem?

Everyone normally sweats while exercising, in anxiety provoking situations, in a hot room. But what if you were drenched all the time – even in a cold room? Would you like to shake hands with someone whose hands are soaking wet with sweat?

Sweating is a normal process by which the body is able to cool itself. For unknown reasons, the part of the nervous system responsible for controlling body temperature becomes dysfunctional and the result is exaggerated sweating (hyperhidrosis), at variable (and often inopportune) times during the day and on various parts of the body. It is the nervous system which stimulates the excessive sweating – the sweat glands themselves are absolutely normal.

About 3% of the world population suffers from this condition, called hyperhidrosis, or excessive sweating. It affects both men and women, all races and ethnicities, teens and adults. Even young children and infants can have hyperhidrosis. And it runs in families, too, although many family members may not share that information with each other. People with hyperhidrosis produce up to five times the amount of sweat required to regulate body temperature. And as an added insult, the excess sweat that is produced is frequently acted upon by the normal bacteria on the skin surface to produce bad body odor (bromhidrosis).

The presence of hyperhidrosis takes a toll on one’s everyday life – and it can ruin lives. One has to be ever vigilant, take several showers a day, remember to bring extra clothing in which to change during the course of a day, carry absorbent pads, etc. Clothing and shoes can be ruined; skin infections can occur; dry cleaning bills can sky rocket. Personal, social and business plans have to be very carefully arranged to accommodate potential problems. Indeed, hyperhidrosis can affect one’s emotional, psychological, financial, physical, social and even one’s professional life. It influences every decision and every moment. Hyperhidrosis is embarrassing and therefore no-one talks about it – they suffer in silence. And unfortunately, many times patients do not seek adequate treatment because they do not know that treatment options actually exist.

TELL ME ABOUT SWEAT GLANDS
There are approximately four million sweat glands on the body – three million eccrine glands and one million apocrine glands. Eccrine sweat glands are contained entirely within the skin itself and are responsible for normal, casual-type sweating. These glands are distributed over the entire body but are concentrated on the forehead and soles of the feet, followed by the palms and the cheeks. The sweat produced is a thin, clear, odorless fluid.

Apocrine sweat glands, parts of which extend beneath the skin into the underlying fat, are responsible for the sweating associated with anxiety and of hyperhidrosis. These glands are mainly located mainly in the hair-bearing areas of the armpits and the groin. They produce a thick, odorless sweat which is prone to rapid bacterial decomposition, which then leads to strong odors. It is the portions of these apocrine glands (the bulbs that produce the sweat itself) that extend into the fat beneath the skin that makes it possible for surgery to remove them. In the armpit areas, the ratio of eccrine to apocrine sweat glands is approximately one to one.

ARE THERE DIFFERENT TYPES OF HYPERHIDROSIS?
Primary (focal) hyperhidrosis, oftentimes starting around puberty, is excessive sweating which is not caused by another medical condition. Most commonly, the armpits (technically called the axillae), the hands, the feet and the groin are involved. Occasionally, the face, back and chest are also affected. The sweating is usually symmetric (ie. both sides equally affected) and rarely occurs while sleeping.

Secondary hyperhidrosis is excessive sweating as a side effect of another medical condition, such as menopause, cancer, diabetes or of taking some medications. It often occurs while sleeping.

TREATMENT OPTIONS
Hyperhidrosis (Excessive Sweating) There are a number of treatment options for primary, focal hyperhidrosis. Treatment for secondary hyperhidrosis should be directed towards correction, if possible, of the underlying causes.

For primary hyperhidrosis, it is best to start with simple methods and then, if they fail, progress to more aggressive treatments.

Initially, one should consider anti-perspirants, either over-the-counter (OTC) (e.g. Secret Clinical Strength) or by a doctor’s prescription (e.g. Hydrosal Professional). Deodorants merely deal with odor, not with the underlying perspiration problem. Combination anti-perspirants and deodorants may be a good starting treatment. Twice daily treatment is often helpful. Obviously, these treatments are only suitable for the armpit area.

For treatment of the hands and feet, iontophoresis may offer help. This 20 minute, painless treatment uses a water bath of electrolytes and chemicals in which a mild electric current is passed. The electric current forces the minerals and ions to plug up the sweat ducts. Usually every other day treatment for six to ten treatments is required. Improvement may last for several weeks, at which time additional treatment is required. This treatment machine may be prescribed for home use.

Emotions also play a large role in sweating. Some natural therapies such as relaxation techniques, yoga, biofeedback and psychotherapy are capable of breaking up the self-perpetuating cycle of heightened emotions leading to sweating which leads to anxiety about the sweating itself which leads to even more sweating. These techniques require multiple sessions and are not totally effective or reliable.

Botulinum toxin (e.g. Botox, Dysport) injections have been successfully used for all areas – armpits, hands, feet and face. There is mild discomfort during the injections which can be helped with numbing creams and ice packs. Since Botox works to block the nerve stimulation of the sweat glands, it works on both types of sweat glands to produce significant dryness. The improvements are apparent within days and oftentimes last for 4 – 12 months or longer – it is extremely variable. While there is no doubt that these injections are very helpful, the long-term cost of the treatments may be prohibitive.

Another treatment is with anticholinergic, anti-anxiety, anti-depressant and other medications (such as Robinul, Inderal, Clonidine, etc). These are pills which affect a portion of the nervous system. They help to decrease anxiety and sweating over the entire body but by doing so, will affect the body’s natural ability to cool itself. Long-term use is not recommended due to significant side effects of the medication.

When all else fails, surgery become an option. There are two alternatives: surgical sympathectomy and suction curettage. How do they work?

Sympathectomy is an operation, performed under general anesthesia in a hospital, which cuts the sympathetic nerves to the armpit and palm areas. It is performed using minimal incisions and is known as ETS or endoscopic thoracic sympathectomy. Once this is performed, there is no way to reverse the operation. The operation interrupts the nerve stimulation to the sweat glands. Unfortunately, there is oftentimes post-operative compensatory sweating, in which the body switches the excess sweating to other areas of the body – and which may be worse than the original problem. This can occur even years after the original surgery.

A new and relatively simple surgical procedure for hyperhidrosis of the armpits (“Sweat Lipo” surgery) has been recently been developed and perfected by Dr. Jacobs. It is performed in a 45 minute operation under sedation and local anesthesia on an out-patient basis in our fully accredited (by The Joint Commission) hospital-type office operating room suite. The procedure uses specialized, sharp instruments designed by Dr Jacobs to perform a direct removal of the sweat glands of the armpit areas. Technically, it is called suction curettage, although it goes by the easily remembered term "Sweat Lipo." Details of the operation are described below.

"SWEAT LIPO" SURGERY
"Sweat Lipo" surgery can only be performed only in the armpit areas. A single, 1/8 inch incision is made at the front of the armpit crease. The instrument is inserted and directed towards the undersurface of the armpit skin. Strong suction is applied and then, with a combination of suction and sharp scraping against the skin’s undersurface, the bulbs of the apocrine glands (which produce the sweat) are removed. The result is that the apocrine glands will be rendered inoperative. However, the eccrine glands in the treated areas will remain intact and continue to function. Therefore, a significant reduction – but not total elimination – of sweating will occur.

"Sweat Lipo" surgery for hyperhidrosis is performed under sedation anesthesia which is administered by a separate, board certified, MD anesthesiologist. There is absolutely no pain or awareness during the procedure. You will awaken quickly after surgery, with no nausea, grogginess, sore throat or hangover. The wounds are closed with a single, dissolving suture. This results in a small scar which, in time, becomes nothing more than a blemish. Dressings will be applied after surgery and worn for only 2-3 days. There is minimal discomfort (mild soreness) after surgery – usually handled by simple Tylenol pills. Most patients are back to sedentary work within a day or two.

One may expect some swelling, bruising and numbness of the skin – all of which are temporary and will disappear within one to two weeks.

There is usually a significant decrease in sweating within a few days after surgery.

FREQUENTLY ASKED QUESTIONS

What are the possible risks, complications and side effects from "Sweat Lipo" surgery?
As in all operations, there are risks of bleeding and infection. In fact, these possible complications are exceedingly rare. The most common side effect has been that some of the armpit hair becomes sparser. This is due to the simultaneous removal of some of the hair-forming bulbs, which lie under the skin in a position similar to the sweat-producing bulbs. For some patients, this is actually an added, though unexpected, benefit.

Will "Sweat Lipo" surgery cure my body odor (bromhidrosis)?
Probably not, but it will make it more manageable. Bromhidrosis results from the normal skin bacteria acting on any sweat that is produced, be it from apocrine or eccrine glands. If the total amount of sweating is reduced, then the bromhidrosis should be similarly reduced. But normal precautions with showers using anti-septic soaps, anti-perspirants and deodorants will probably still be required. Sometimes, antibiotic skin creams may also be used as well.

How long will the results of "Sweat Lipo" last?
This is unknown mainly because it is a new procedure. There are no long term studies as yet. However, patients have remained significantly drier for at least one year after surgery…..and counting.

Will I be absolutely dry after "Sweat Lipo" surgery?
No. The surgery will remove the apocrine glands, but the eccrine glands will be untouched and will continue to function. Hence, you will still sweat – but the problem will be much more manageable.

I don’t sweat excessively but would just like to cut down on the amount that I do sweat. Can this procedure work for me?
No. This procedure is not meant as a treatment for casual sweating. Rather, it should be considered only for those patients with hyperhidrosis and only when all other conventional methods have failed.

Will insurance cover the cost of "Sweat Lipo" surgery?
Doubtful. Most insurance companies will consider this treatment “experimental” and thus be reluctant to provide coverage for it. Interestingly, insurance companies may cover Botox treatments, but not this surgery (as yet).

Can Botox treatments be incorporated before, during or after "Sweat Lipo" surgery?
Yes, this is possible.

Is there any clothing that I can buy which can help with my hyperhidrosis problem?
Yes, there are some manufacturers who design specific clothing for people with hyperhidrosis. One such manufacturer is: www.silverbackapparel.com/hyperhidrosis. And for sweaty feet, one can look into www.summersoles.com, which are super-absorbant foot inserts.

Are there any new treatments on the horizon?
Yes, scientists are studying a new type of cream that has Botox-like effects. However, since it is a cream, it can be applied to skin rather than requiring an injection. It will most likely be available only by prescription.

Dr. Elliot Jacobs, M.D., Plastic Surgeon
815 Park Avenue
New York, New York 10021
Telephone (212) 570-6080

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