Diagnosis and management of hyperhidrosis
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6800 (Published 25 November 2013) Cite this as: BMJ 2013;347:f6800
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Hyperhidrosis in patients with amalgam in their teeth.
Fredrik Berglund, MD, PhD.
Solvägen 8A, 192 60 Sollentuna, Sweden
fred.berglund@swipnet.se
In a recent clinical review of hyperhidrosis, sympathectomy and botulin toxin were recommended. A serious drawback of sympathectomy is the occurrence of compensatory hyperhidrosis in areas of the body not previously affected. Botulin toxin has to be given at least twice a year.
Recently I made a search for svett (Swedish for sweat) among 880 amalgam patients seen over a period of 20 years. Hyperhidrosis was not the main complaint, although incapacitating for some. After complete removal of dental amalgam 51 patients were markedly improved or completely free of hyperhidrosis. Several patients mentioned sweating of various causes (endocrine, fevers), but hardly of type hyper-hydrosis. Seven patients, including one dental assistant, reported inability to sweat, that was normalized after amalgam removal.
Mercury is continuously released from amalgam. A number of papers report on hyperhidrosis caused by the industrial use of mercury and in children playng with mercury (2). From the year 2009 the use of mercury is banned in Sweden. But more than half of the Swedish population still carry dental amalgam. The medical profession should pay attention to the presence of amalgam in the teeth!
References
1.
Benson RA. Diagnosis and management of hyperhidrosis. BMJ 2013;347:f6800.
2.
Shih H, Gartner JC. Weight loss, hypertension, weakness, and limb pain in an 11- year old boy. J Pediatr 2001;138:566-9.
Competing interests: No competing interests
Sir
In their recent review of primary hyperhidrosis, Benson et al1 consider available oral treatments for
primary hyperhidrosis, but erroneously state that “oral anticholinergic drugs are not currently licensed for UK use in primary hyperhidrosis”. The authors advise oral glycopyrrolate and oxybutynin can be “trialled in secondary care at the clinician’s discretion”, but make no mention of Pro-Banthine (pro-pantheline), which is licensed to treat hyperhidrosis,2 and has been prescribed in primary and secondary care for many decades. We became aware of many successfully treated patients after Archimedes Pharma UK Ltd had received over 2,000 calls from pharmacists and patients seeking continuation of supply when it had become temporarily unavailable in 2012. On follow-up, of those pharmacists who could recall the reason Pro-Banthine had been prescribed, the great majority (85%) indicated that it was for patients suffering from hyperhidrosis. Similarly the recently updated NICE Clinical Knowledge Summary on hyperhidrosis3 advises that glycopyrronium may be imported or Oxybutynin tried, but makes no reference to Pro-Banthine, which is licensed for this condition.
Like all anti-muscarinics, Pro-Banthine may be limited by its side effect profile, and it is important to take it on an empty stomach before meals. Compliance may be limited by its qds dosing when compared to slow-release once-daily preparations like Lyrinel XL (Oxybutynin), but it is licensed and clearly effective for many patients suffering with this condition, and it is also significantly cheaper. We recommend it be considered as a second line treatment in moderate to severe focal or more generalised hyperhidrosis.
References
1. Benson RA, Palin R, Holt PJE, et al. Diagnosis and management of hyperhidrosis. BMJ 2013;347
2. Marketing Authorisation Number: PL 12406/0026
3. NICE Clinical Knowledge Summary: Hyperhidrosis; revised July 2013
Competing interests: No competing interests
Madam,
In their recent review of primary hyperhidrosis, Benson et al considered the available surgical treatments for primary hyperhidrosis, mentioning endoscopic thoracosympathectomy and the emerging options of suction curettage and laser.[1] They did, however, omit to mention the established, effective and minimally invasive procedure of selective sweat gland removal with minimal skin excision, first described by Hurley and Shelley in 1963[2], and later reported by Lawrence et al in 2006[3] to be an effective treatment for axillary hyperhidrosis.
We evaluated this procedure in 28 consecutive patients in whom standard topical treatments and intradermal Botulin A toxin had failed. Two outcome measures were used: the dermatology life quality index (DLQI) and patient rating of their axillary sweating on a 0-10 visual analogue scale (VAS). There was a mean reduction in the DLQI of 10 and a mean percentage reduction in the DLQI of 48%. This was reflected by mean percentage reduction in axillary sweating on VAS of 51%. Furthermore, 76% of the patients would recommend the procedure.
As with all surgical treatments, scarring, paraesthesiae and infection are potential complications. However, being a relatively non-invasive procedure performed under local anaesthetic (unlike endoscopic thoracosympathectomy or suction curettage), the risk of general anaesthetic and significant potential side effects associated with endoscopic thoracosympathectomy can be avoided. It is at present one of only three relatively non-invasive techniques available for the treatment of axillary hyperhidrosis: the second being laser, which would appear to have limited evidence of efficacy; the third being microwave technology[4], which is showing promising preliminary results in the United States, but has not yet become established in the United Kingdom. We would recommend consideration of this selective sweat gland removal with minimal skin excision (Shelley’s Procedure) for patients with primary axillary hyperhidrosis in whom topical treatments and Botulin A toxin have failed.
References
1. Benson RA, Palin R, Holt PJ, Loftus IM. Diagnosis and management of hyperhidrosis. BMJ. 2013;347:f6800
2. Hurley HJ, Shelley WB. A simple surgical approach to the management of axillary hyperhidrosis. JAMA. 1963;186:109–112.
3. Lawrence CM, et al. Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis. Brit J Dermatol 2006;155: 115-8.
4. Glaser DA, Coleman WP, Fan LK et al. A randomized, blinded clinical evaluation of a novel microwave device for treating axillary hyperhidrosis: the dermatologic reduction in underarm perspiration study. American Society for Dermatologic Surgery 2012; 38:185-191
Competing interests: No competing interests
We read with interest the review article by Benson et al on treatment for hyperhidrosis. The patient should be informed and given the choice of different minimally invasive approaches to sympathectomy, including conventional video-assisted thoracic surgery (VATS) which utilizes incisions of 5 to 10 mm in length, or specialized technique of needlescopic VATS which have incisions of 3mm only. [1] More recently, single incision (uniportal) VATS sympathectomy has been reported which may further reduce surgical access trauma. [2] Furthermore, the choice of sympathectomy (usually referred to excision of a section of the nerve) or sympathicotomy (interruption of the nerve) should also be discussed with the patient. The advantage of sympathectomy is that recurrence of hyperhidrosis is less likely, but may be associated with more severe compensatory hyperhidrosis. [1,3]
Prior to performing surgical sympathectomy, another important consideration is the patient’s resting pulse rate. The Society of Thoracic Surgeons guidelines suggest that patients with a resting heart rate lower than 55 per min are unsuitable for this procedure because of potential exacerbation of bradycardia following sympathectomy. [3] In addition, patients should be warned that there is some evidence sympathectomy may affect cardiac ejection fraction based on echocardiographic findings, which may consequently reduce peak exercise performance. Such warning would be particular prudent for athletes considering this surgical procedure. [4]
Finally, although patients should be warned of the irreversible nature of the surgical procedure, in highly specialized centers, reversing the sympathectomy by nerve graft can be attempted for those with severe side effects of compensatory hyperhidrosis. [5] In the current environment of medical litigation, we can never be too careful in our consent for an essentially lifestyle surgical procedure.
References:
1. Ng CSH, Lau RWH, Wong RHL, Yim APC. Evolving Techniques of Endoscopic Thoracic Sympathectomy: Smaller Incisions or Less? The Surgeon 2013;11:290-291
2. Ng CSH, Yeung ECL, Wong RHL, Kwok WT. Single-port Sympathectomy for Palmar Hyperhidrosis with VasoView HemoPro 2 Endoscopic Vein Harvesting Device. J Thorac Cardiovasc Surg. 2012 Nov;144(5):1256-7
3. Cerfolio RJ, De Campos JR, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011;91(5):1642-8
4. Cruz JM, Fonseca M, Pinto FJ, Oliveira AG, Carvalho LS. Cardiopulmonary effects following endoscopic thoracic sympathectomy for primary hyperhidrosis. Eur J Cardiothorac Surg 2009;36(3):491-6
5. Wong RHL, Ng CSH, Wong JKW, Tsang S. Needlescopic video-assisted thoracic surgery for reversal of thoracic sympathectomy. Interact CardioVasc Thorac Surg 2012;14:350-2
Competing interests: No competing interests
Sir/Madam,
We believe Dr Manassiev has posted his concerns due to the following statement:
“The glands are innervated by the sympathetic nervous system. Acetylcholine is the primary neurotransmitter. Spinal cord segments T2-8 supply the skin of the upper limbs, T1-4 the face and eyelids, T4-12 the trunk, and T10-L2 the lower limbs. (Reference 14)”
These segments are used to describe the thoracolumbar sympathetic supply, which is responsible for supplying the sweat glands related to hyperhidrosis. The thoracolumbar sympathetic fibres arise from the dorso-lateral region of the anterior column of the grey matter of the spinal cord. These fibres do pass through with the spinal nerves which Dr Manassiev has referred to, but unfortunately do not correspond to the distribution of dermatomes in the same way as he has kindly described.
The sympathetic fibres supplying the skin of the trunk and limbs, for example, leave the spinal cord in all the thoracic and the upper two or three lumbar spinal nerves. The sympathetic supply to the head comes from the upper thoracic nerves.
The authors apologise if it was not made adequately clear that we were describing the sympathetic supply to the areas affected most significantly in hyperhidrosis. The supporting reference in the text should confirm this.
We agree with Dr Motley’s concerns regarding the problems patients have when using 20% aluminium chloride preparations. Although we have stated that it should be applied to dry skin, and that irritation is a known issue, we were unable to include more detailed instructions due to limitations to the length of the review. This unfortunately may have had the effect of underestimating the discomfort that some patients experience when using these treatments.
Unfortunately these preparations are also easily available to purchase over the internet, without prescription. If bought in this way, the chance to discuss these treatments and the best method of application with a medical professional is lost completely.
We would like to thank Dr Sharvill for highlighting the issue of varied availability of treatments across the UK, especially with regards to botulin toxin injections. The article serves to describe the stepwise management for hyperhidrosis, and the treatments available in a generic fashion. In some areas, botulin is licensed, but only for those with a score of severe on the hyperhidrosis disease severity score. With regards to Oxybutynin provision, the authors agree that this can be provided in primary practice, although not all practitioners are familiar enough with its use in this setting. It is hoped that this article provides supporting evidence to allow them to do so with confidence.
Competing interests: No competing interests
Is it not embarrassing? Authors state that T2-8 supplies the skin of the upper limbs. Patently not as any lay person could tell by simply looking at a dermatome chart on the internet. Perhaps the authors mean C2-8. Even this is wrong, as any anatomy student would notice on opening an anatomy or neuroanatomy textbook - C2 and C3 do not supply the skin of the upper limbs, but the back of the head and the neck. It is embarrassing, but not just for the authors, but for the BMJ peer reviewers and the BMJ editors too. Does anyone read the BMJ articles carefully, or I am taking my medicine too seriously?
Competing interests: No competing interests
Sir,
I was disappointed that the authors of this recent review of the management of hyperhidrosis did not provide more comprehensive instructions about the use of alcoholic 20% aluminium chloride preparations, without which many patients will be destined to experience only skin irritation. When water, in the form of sweat, comes into contact with a saturated alcoholic solution of 20% aluminium chloride, it causes the formation of hydrochloric acid, which is the principle cause of skin irritation. Aluminium chloride 20% alcoholic solution should only ever be applied to dry skin - initially for a few hours, gradually increasing to overnight. It should always be thoroughly washed off at the first sign of significant sweating, and in the morning. When used in this manner it is highly effective at controlling sweating without irritating the skin. Unfortunately many patients are prescribed these products without adequate counselling, and intuitively apply them during the day in the same way as 'normal' antiperspirants and develop severe skin irritation as a consequence.
Competing interests: No competing interests
Good article but there seems to be no reflection of NHS funding restrictions, availability of treatments or the ability of normal GPs to manage this without referral. In our area iontophoresis ceased being available on the nhs, having previously been provided by physiotherapists, and some patients seem to be happy to buy the kits after referral to the hyperhidrosis website. Why do GPs need to refer before prescribing oxybutinin? Botox is not available on the nhs for treatment as deemed to be a low priority procedure. Glycopyrrrolate is, I think, only available as a 'special' and is very expensive to the nhs.
Competing interests: No competing interests
Re: Diagnosis and management of hyperhidrosis
Hyperh[i]drosis, that is excessive sweating, is not a recognised medical condition. Excess sweat, if not a symptom of another illness, is caused by inadequate release of oxygen from the body. Excessive sweating has to be dealt with by making sure the patient is breathing out fully and rhythmically. There is little point in prescribing useless deodorants, recommending salt baths or surgery until the patient has tried to regulate their breathing.
The Blacks’ Medical Dictionary does not hold an entry for the condition of Hyperhidrosis.
Hugh A. Lawson BSc(Hons)
Competing interests: No competing interests