Sweat glands
Key points
Hyperhidrosis
Definition: Excessive sweating beyond what is required for thermoregulation
Effects: psychosocial, emotional, functional, cosmetic, hygienic
Pathophysiology
2 types of sweat glands - Eccrine and apocrine Eccrine glands open directly onto skin, apocrine glands open into hair follicle and also contribute to body odour
2 types of sweating - thermoregulatory (hypothalamus) and emotional (limbic system)
Most important areas are face, axilla, palms and soles of feet
Control is by autonomic nervous system (sympathetic cholinergic - mostly sympathetic nerves, but ACh is main neurotransmitter, hence efficacy of botox )
2 types of Hyperhidrosis: Generalised/focal, primary/secondary
Generalised hyperhidrosis causes:
Anxiety
Hyperthyroidism
Phaeochromocytoma
Carcinoid
Lymphoma
Primary focal hyperhidrosis (affects 1 or all 4 of face, axilla, palms, soles of feet)
Always symmetrical. Functional, cosmetic, hygiene, psychosocial effects
Secondary focal hyperhidrosis can be caused by tumours and cervical ribs
Hyperhidrosis disease severity scale:
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
Management
Topical antiperspirants – 20% Aluminium chloride
Topical Glycopyrrolate ( For craniofacial hyperhidrosis )
Oral anticholinergics: Oxybutynin and Glycopyrrolate
Side effects: dry mouth, abdominal symptoms, constipation, urinary retention, tachycardia, drowsiness, blurred vision
Botox injections - Works by blocking pre-synaptic ACh release temporary lasting 6-9 months, and antibodies are formed, decreasing efficacy. Painful, may not be tolerated
For plantar and palmar hyperhidrosis: Water iontophoresis - mechanism unknown - possibly by cross linking mucins and blocking duct - 70-80% success
30 minutes a day, 3 times per week, 1-3 months
Surgical management options
For Axillary Hyperhidrosis:
Microwave therapy - heat energy destroys eccrine glands
Fractionated microneedle radiofrequency
Liposuction
Curettage
Skin excision
Bilateral thoracoscopic thoracic sympathectomy
Thoracoscopic approach
Identify sympathetic ganglion in the posterior mediastinum
Identify and preserve the stellate ganglion
Ablate the ganglion (Excision, electrocoagulation or clips)
Clips preferred for easier reversal
Identify and ablate the accessory ramus of Kuntz
The nerve of Kuntz is an inconstant intra thoracic ramus arising from the 2nd thoracic nerve carrying the sympathetic fibres joined with either 1st thoracic or 1st intercostal nerve or stellate ganglion to contribute the sympathetic innervations to the upper limb
For palmar hyperhidrosis - clip or cut the sympathetic chain over rib 3 (above T3 ganglion) or rib 4
The hands must be exposed during the operation, as vasodilation will occur and show efficacy
For axillary or plantar - clip or cut the chain over rib 4 or 5
Do not do if only isolated plantar hyperhidrosis
For facial hyperhidrosis - clip or cut the sympathetic chain over rib 3
Complications
Compensatory hyperhidrosis - more likely if chain interrupted at higher levels
Horners syndrome
Bradycardia
Gustatory sweating
Failure/recurrence
Clips can be removed if needed
Hidradenitis Suppurativa
Occurs in intertriginous skin
Occlusion of follicles
Chronic inflammation
Scarring
Hurley staging system
1: Abscesses only, no tracts or scars
2: Recurrent abscesses + tracts + scars
3: Diffuse connected abscesses + tracts + scars - most of area involved
Medical management:
TNF α inhibitors - Adalimumab for stage 3
Laser + light therapy
Surgery: Wide excision for areas not responding to medical management
Page edited by Mrs Charnjit Seehra BSc November 2024
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. January 2025
References
Brackenrich J, Fagg C. Hyperhidrosis. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459227/
Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis. 2017 Apr;9(Suppl 3):S178-S192. doi: 10.21037/jtd.2017.04.04. PMID: 28446983; PMCID: PMC5392541.
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 May;91(5):1642-8. doi: 10.1016/j.athoracsur.2011.01.105. PMID: 21524489.
Ballard K, Shuman VL. Hidradenitis Suppurativa. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534867/