Wednesday, 4 January 2012



Imagine getting ready for work and having to change clothes before you even leave the house because you've already sweated through your first shirt. After carefully padding the armpits of the new shirt to try to prevent sweat from drenching it, you make sure to bring a few spares so you can change later in the day. Breakfast proves to be a challenge when the warm mug keeps slipping from your sweaty palms, and keeping a grip on your fork is a challenge. You're relieved you didn't accept the breakfast invitation from your co-workers -- this ordeal is unbearable in front of other people. Your sweaty hands make it difficult to grip the steering wheel, so you must drive extra cautiously. By the time you arrive at work, your socks and shoes are soaked with sweat. And so, sitting down at your desk, you sigh and begin the struggle of getting through another day. This is a glimpse of what life can be like for someone with hyperhidrosis. Sweating happens all the time; it doesn't need the presence of a normal trigger like exercise, hot weather or anxiety. Hyperhidrosis, also called diaphoresis, involves extreme or excessive sweating. People with this condition may sweat at levels four or five times what most people experience. These levels are far beyond what is considered normal or necessary for the body to keep cool. This condition can take several forms, and it varies in severity from person to person.

Living with Hyperhidrosis
Hyperhidrosis isn't life-threatening, but it can affect every aspect of someone's life, and the effect on his or her psyche can be devastating. The worst part may be that while some triggers -- like spicy food or hot weather -- can be avoided to a greater or lesser extent, hyperhidrosis doesn't need a trigger. It can happen at any time with no warning at all. It's no surprise that people with hyperhidrosis often report depression, social anxiety, decreased confidence levels, difficulty forming close relationships, frustration at daily activities, reduced work performance and a self-imposed isolation. Furthermore, the same social embarrassment and anxiety someone with hyperhidrosis may get from sweating can cause them to sweat even more, creating a vicious cycle that seems impossible to break.

Important facts about Hyperhidrosis:
  • Hyperhidrosis affects between 1 and 2% of the world's population.
  • In certain geographic regions the percentage appears to be more than 2% (Taiwan, Philippines, etc).
  • There is no known difference in those who are affected with regard to race or gender.
  • Family genetic history is believed to play a major role in hyperhidrosis.
  • The most common areas of localized hyperhidrosis are the hands, feet and armpits.
  • Hyperhidrosis can negatively affect people both socially and functionally in their daily lives.
  • Those suffering from excessive sweating for whom conservative treatments have failed there are now new outpatient surgical procedures available to end hyperhidrosis.
  • Historically doctors have underestimated and or misunderstood the significant impact hyperhidrosis has on patient's lives.
  • Continual advancements are being made in instrumentation and techniques.
  • Conservative treatments have limited success rates.
  • There are now unique and highly effective surgical treatments for each type of sweating (hands, feet and armpits)
In most people, low-level sweat production is a constant process, and much of that sweat doesn't even come out of the sweat glands; it's simply reabsorbed by the body. High-level sweat production is another matter. The process can kick off from exercise, high temperatures or stimulation from nerves in response to an emotion, like anxiety or fear.

Normal causes of excessive sweating:
  1. Sweating among teens is normal as it may be due to obesity contributed by junk foods.
  2. Junk foods may lead to excessive sweating as body temperature rises to burn the calories of consumed.
  3. Anxiety and nervousness are other major factors for hyperhidrosis and spelling it as  hyperhidrosis correct too.
  4. Change in environment or warm climatic conditions.
  5. Prolonged illness and fever may release sweat to cool down body heat.
  6. Certain food contents like caffeine in coffee and side effects of medications like morphine and aspirin is reported to contribute more in sweating.
  7. In women the cause of excessive sweating can be improper mensus or menopause.
  8. Emotional and psychological imbalance, like thinking mostly on negative aspects.
  9. Alcohol withdrawal and narcotic analgesics.
  10. Many phobias too contribute in sweating like bacteriophobia, cacophobia, Ombrophobia and many more.
The nerves that react to stress get their cues through the sympathetic nervous system, which in turn is part of the autonomic nervous system. The sympathetic nervous system is responsible for preparing the body to respond to dangerous or stressful situations. When something of this nature occurs, the sympathetic system readies the body in a number of ways -- including increasing sweat production. It does this by stimulating the sweat glands with a chemical neurotransmitter called acetylcholine. This chemical rests in tiny sacs located between the nerves and sweat glands until it is needed. When released, this chemical forces the sweat glands into action, and the glands will continue to react until the acetylcholine has been depleted. (If the perceived threat hasn't passed at that point, more acetylcholine is released for the reaction to continue.)

For people with hyperhidrosis, the nerves that serve the sweat glands in certain portions of the body will go into overdrive from time to time and produce sweat for no reason at all. The frequency, duration and strength vary by person. There is no conclusive evidence as to why the nerves do this, but they will bombard sweat glands with unnecessary acetylcholine, causing a very sticky situation for some people.

Two forms of hyperhidrosis exist, primary and secondary.

The primary form affects localized areas - the palms, the soles, underarms and forehead. It most commonly begins during childhood or just after puberty. There is frequently a family history, too. Primary hyperhidrosis is bilateral and symmetrical. If one palm is affected, so is the other. It can't be just one side of the forehead that sweats in excess, it's the entire region. Anxiety, heat and exertion are common triggers. It is unlikely that these patients will experience problems with sweating while asleep. We still do not fully understand why some individuals are afflicted by this condition. While hyperhidrosis can be the result of simple genetics, problems such as neurological diseases/trauma can cause this condition. But unlike secondary hyperhidrosis, there are no underlying medical conditions.

Secondary hyperhidrosis refers to a generalized form of excessive sweating. Most women who have gone through menopause are personally acquainted with the hot flash, in essence a transient form of secondary hyperhidrosis. 

Other possible causes include:
  • Hyperthyroidism
  • Diabetes
  • Neurological Disorders (including paralysis)
  • Malignancy
  • Tuberculosis (and other chronic infections)
 Main focal areas include:
·         Armpits (axillary hyperhidrosis)
·         Hands (palmar hyperhidrosis)
·         Feet (plantar hyperhidrosis)
·         Face and other parts of the head (facial hyperhidrosis)

Hand Sweating / Palmar Hyperhidrosis

Excessive hand sweating or as it’s known as palmar hyperhidrosis, is the most common form of excessive sweating. Those who suffer from it start having the symptoms at a young age usually grade school. Its intensity can vary among people. The intensity of excessive hand sweating can vary from just moisture on the hands to literally dripping wet. Obviously the extreme cases are very troublesome and can prevent those patients from performing simple daily tasks. It does have a genetic relation and about 50% of the patients have a family history with the condition. Recently the exact genetic location was found but a practical treatment with these new findings is still a long ways off. It can affect a person on a functional, emotional, and social level.

This condition is primarily a physiological issue but it can be aggravated by emotional stimuli. Physiological meaning that the person cannot control the level of sweating or timing of it. Attempts to control this condition are numerous and they range from lotions, pills, herbal medications, bio feedback, electric currents (iontophoresis), acupuncture, to surgery. It should be emphasized that patients who suffer from severe excessive hand sweating should try at least some of the conservative approaches before any decision is made to go ahead with surgery. The information obtained should be read carefully because a good portion of the medical community is not aware of the available new methods to treat this problem. Many physicians lack the information needed to provide their patients with the different options.

Excessive Hand Sweating Surgical Solution
In the past surgery meant a very extensive and invasive approach to get to the sympathetic nervous system located in the chest cavity. This particular fact prevented the operation to be done on a large scale. The improvements in the surgical approach (endoscopic surgery) and the surge of information available on the Internet have made it easier for patients to know, learn, and receive surgical treatment. Surgical intervention is the only known method that can provide long-term relief of excessive hand sweating.

It is common now days that the Endoscopic Thoracic Sympathectomy (ETS) is performed on an outpatient basis which means the operation is carried out in a relatively short period of time and the patient can go home or to their hotel a few hours later. Also the amount of pain and discomfort is limited. Most of the patients can go back to their normal life (work, school, etc) within a very short time.


Foot Sweating / Plantar Hyperhidrosis

Foot sweating or as it’s known in the medical literature as plantar hyperhidrosis is also a part of the focal excessive sweating syndrome. It may not have the same social impact on the patient as hand sweating but can be very bothersome to people. Over the last few years when more follow-up on patients who had ETS done it became obvious that excessive foot sweating (plantar hyperhidrosis) can pose the same social and functional difficulties that patients have with excessive hand sweating. We also noticed that the success rate for plantar hyperhidrosis after performing ETS is not more than 20%. Stories like severe embarrassment from the smell, necessity to change shoes and socks constantly are being heard more often.

Lumbar Sympathectomy - Surgery Specifically for Excessive Foot Sweating
Now lumbar sympathectomy is offered as a surgical solution for those cases with severe plantar hyperhidrosis or plantar foot sweating. It should always be remembered that attempts should be carried out with some of the conservative measures that are available such as drysol, drionic or anti cholinergic agents. Recent evidence from different centers in the world showed that this operation is very effective to treat excessive foot sweating. This operation cannot be done at the same time as Thoracic Sympathectomy. An average of three to four months is needed to perform both operations. This is a cautious approach to ensure the body responds well to each operation. At present a good percentage of patients have the procedure done on an outpatient basis.

New Information on Lumbar Sympathectomy:
This operation is done endoscopically and there are three small cuts made on the left and right side of the body. In cases of technical difficulties, which are very rare, the surgery can be done in an open fashion through one incision and the difference in the amount of pain is minimal. At present not only is the operation done endoscopically but the operation can also be accomplished on an outpatient basis where the patient leaves the hospital on the same day. 

The Success Rates for Different Types of Procedures:
ETS is very successful for those suffering from focal palmar hyperhidrosis (Sweaty Hands). With ETS those who also suffer from plantar hyperhidrosis (sweaty feet) the success rate is very low. For those patients with remaining plantar hyperhidrosis the lumbar sympathectomy is now offered with a great deal of success. This is also true for people who suffer from isolated plantar hyperhidrosis and never had ETS done. The success rate of ELS is about 97 to 98%. 

Facial Blushing and/or Sweating


Facial blushing also known as social phobia or erythrophobia is another manifestation of hyper sympathetic activity. Facial blushing is sometimes mistaken as rosacea.

It was found that patients who suffer from palmar hyperhidrosis (hand sweating) as well as facial blushing will benefit from sympathectomy. Then the scope of sympathectomy was increased to include patients who suffer only from facial blushing.

Facial blushing usually appears late in life teenage years and up and is manifested with bursts of facial redness which are social triggered. Patients can feel warm feeling in their facial area but the hallmark of their complaint is that their face is changing into a red colour. Those afflicted with that can have social and functional impact on their lives.

Over the last several years sympathectomy as a surgical cure for facial blushing lost its significant role as a treatment due to lower success rate and the fact that patients are sometimes left with various side effects that are less desirable than the facial blushing itself. Accumulating information and evidence over the last few years has shown that a high number of patients who were treated surgically for facial blushing and or facial hyperhidrosis did develop more side effects than those who were treated for palmar hyperhidrosis as a presenting problem. Dr. Reisfeld has written extensively about this on his website covering facial blushing.
Treatement can be done with medications such as betta blockers, tranqulizing medications, and as the last resort sympathectomy. A useful link for people who suffer from facial blushing is the Red Mask Foundation.

Sweaty Armpit / Axillary Hyperhidrosis


Armpit sweating or it’s known as axillary sweating is another form of excessive sweating. It can be associated with palmar hyperhidrosis (hand sweating) in about 40% of the cases or it can be presented on its own as isolated focal axillary hyperhidrosis.

The armpit area has two types of sweat glands, eccrine and apocrine glands. The eccrine glands will be affected by sympathectomy and not so for the apocrine glands. For those patients who have the armpit sweating together with the hand sweating sympathectomy will help in about 80 to 90% of the cases. Never the less Dr. Reisfeld does not recommend sympathectomy for patients who suffer from isolated axillary hyperhidrosis.

Laser Armpit Sweating Treatment: (New Advanced Treatment)
Currently a preferred method to treat isolated cases of axillary hyperhidrosis is the combination of subdermal laser ablation and axillary suction currettage. Over the last few years there was some excitement about using subdermal laser ablation (SDLA) as the only method needed to help patients afflicted with severe isolated armpit sweating (axillary hyperhidrosis). Experience has shown that the success rate obtained with only SDLA is not as good so now the preferred approach is to use SDLA with axillary suction currettage. The SDLA provides an easy way to separate tissues in the subdermal region and to destroy a certain amount of sweat glands but it must be complimented with the mechanical portion of the process which is the axillary suction currettage.

For those who suffer specifically from excessive armpit sweating there is a surgical solution (Subdermal laser ablation) which is 85-90% effective in which the patients are completely satisfied with the results. Experience has shown that complimenting the laser ablation technique with the mechanical suction currettage method ensures a better and more successful end result.

Side effects after the surgery such as pain, discomfort, swelling, fluid accumulation are temporary and can be dealt with easily.

Very few doctors offer this new and advanced approach. Renowned expert Dr. Reisfeld in Los Angeles does offer this new technique.


How does one control excessive sweating? In secondary hyperhidrosis, the cause must be determined and addressed. 
But in primary hyperhidrosis, one can do any of the following:
  • Block sweat from being released by the eccrine gland.
  • Block acetylcholine from reaching it's intended target (the sweat gland)
  • Reduce the amount of acetylcholine being released
  • Remove the sweat glands
Antiperspirants are the first line of hyperhidrosis treatment. All antiperspirants work by blocking the sweat ducts, preventing sweat from reaching the skin's surface. Aluminum (whether combined with chloride or zirconium) is soluble as long as the formulation is acidic. Once applied to the skin, contact with sweat raises the pH, causing the complex to precipitate out and plug the glandular opening.

Oral Anticholinergic Medication
Certain prescription oral medications can prevent the release of acetylcholine, that neurotransmitter responsible for causing the eccrine sweat gland to go into overdrive. Pro-Banthine is frequently recommended and easy to take in a once a day (1.5 mg/kg every 24 hours) dose. Other anticholinergic medications include Ditropan and Robinul. The FDA has not specifically approved the use of these medications in the treatment of hyperhidrosis, so it's definitely an "off label" therapy. The downside to this category of medicine; the potential side effects including dry mouth, blurred vision, constipation, urinary retention and palpitations.

Iontophoresis involves the plugging of the eccrine sweat gland by means of electrical current. Iontophoresis may be used to treat excessive sweating of the armpits, but it is more effective and tolerable (as well as practical) when targeted at problematic hands and feet. The site of choice is submerged in water and electricity is emitted by the device and gradually increased until the patient notices tingling. Three or four 10-20 minute sessions are performed weekly until improvement occurs. Maintenance is performed as necessary. Some amount of skill is needed to see good results. Possible side effects include irritation, dryness or blisters. Skip the concept if you're pregnant, wear a pacemaker or have metal implants.

he panacea of the new millennium, Botox has received FDA approval for the treatment of recalcitrant hyperhidrosis. For the same reason we understand how Botox works to eliminate wrinkles, Botox prevents the nerve from releasing acetylcholine resulting in sweat prevention. Eccrine sweat glands aren't always clustered as one might expect, so prior to the injections, the dermatologist will map out your underarms with a simple process called Minor's starch test. First, make certain to shave prior to your appointment. After sitting quietly for 30 minutes, the skin will be wiped with an iodine swab and allowed to dry. Cornstarch will be lightly dusted across the area. Within a few minutes, the zones where the glands are producing sweat will turn a blue-black color. This is where the treatments will be given, making it unlikely that areas of glandular hyperactivity will be missed. Each underarm will receive 50 units of Botox in a series of small injections (approximately 12-15 per side). Improvement of hyperhidrosis should be seen in just a few days. If excessive sweating persists for 2 weeks, it is prudent to repeat the Minor's test to determine if any areas were missed and do a Botox "touch up". Incredibly, Botox therapy for hyperhidrosis lasts 7 months on average although 28% of treated patients experienced sweat control for as long as 16 months. Approximate cost for this procedure may run anywhere from $500.00 to $1200.00. Botox injections can cause bruising, occasional bleeding, temporary muscle weakness (this is particularly true when injected around the thumb) and rarely allergic reactions. Avoid Botox if pregnant, nursing or if you have a history of neurological condition such as myasthenia gravis.

Endoscopic Thoracic Surgery
Finally, when all else fails, a more invasive procedure known as ETS (endoscopic thoracic surgery) may be considered to conquer primary hyperhidrosis. This is a more radical approach involving the cutting of the nerves (sympathectomy), which trigger the eccrine sweat glands. It is best used to treat hyperhidrosis of the palms. Performed under anesthesia, a small cut is made and the patient's lung on the side of the operation is actually deflated. A small camera is used to visualize the proper nerves to be dissected. After this is accomplished the lung is reinflated and the incision is closed. A good outcome is dependent upon the skill of the surgeon. Make sure if you are considering this operation that your physician is well versed and proficient at this procedure. In addition to possible side effects commonly associated with any surgery, patients may experience compensatory hyperhidrosis (sweating elsewhere such as the back, stomach or lower extremities) or gustatory hyperhidrosis - excessive sweating triggered by eating.

Doctor Rafael Reisfeld - When Experience Counts:
Dr. Rafael Reisfeld, M.D., F.A.C.S., A.B.M.S., is a Board-Certified surgeon, diplomat of the American Board of Surgery, and known worldwide as one of the very best doctors in the unique field of hyperhidrosis. Dr. Reisfeld was one of the first doctors to perform the ETS procedure and continues to perform this surgery, as well as newly developed techniques on virtually a daily basis. He is also one of the only if not the only doctors to perform both the lumbar and thoracic sympathectomy on a routine basis. He is now offering a new less invasive and more efficient laser technique for the treatment of isolated axillary (armpit) hyperhidrosis. He is continually published in various medical journals and has been interviewed by various media outlets such as Newsweek Magazine, Fox News, CBS, and many others for his expertise and knowledge in this field. Dr. Reisfelds primary focus is helping those who suffer from hyperhidrosis and he is tirelessly working to improve methods used to accomplish that goal. Currently more doctors are performing these procedures however you have to consider their experience and level of dedication to these delicate procedures as compared to Dr. Reisfeld who has established himself as a unique leader and expert in advancing the development of this field.
For any potential patient who suffers from severe excessive sweating it is extremely important to talk with the surgeon who performs the operation. Any staff members (for example nurses, office managers and or personnel who do not perform the procedure) are not equipped to answer your questions appropriately. 

Instead of cutting the nerves and preventing the stimulation of the eccrine sweat gland as occurs in ETS, liposuction removes the eccrine sweat glands themselves. Local axillary liposuction is performed as an outpatient surgery. It is not unheard of for some glands to be left behind, thus sweating is often reduced to a more normal level rather than completely eliminated in the treatment area. 


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