Chapters Transcript Video Surgical Cure for Axillary and Palmar Hyperhidrosis in Pediatric Patients Sunghoon Kim, MD, MS presents on Axillary and Palmar Hyperhidrosis. Thank you very much. I'm very happy to give this talk, uh, because I feel that uh hyperrosis, uh, in children is an undertreated, uh, problem. And, uh, uh, when treated, uh, this really affects their life and it could improve their, um, Life outlook tremendously by treating them. OK, uh, the title of the talk, uh, is a little bit different, but it's the same, uh, talk in that it's a treatment of pediatric, uh, palma and axillary hyperhidrosis. I have no disclosure. So that today's goal is to um To recognize primary hyperhidrosis and then also learn about secondary causes. Uh, we're going to learn about how to treat, uh, using, um, practical first line therapies and then the medication options, and then as to, uh, when to identify the patients who would be best served by referring the patient for surgical consultation. So why should the pediatrician uh be care about hyperroidosis? Uh, this problem, uh, typically, uh, starts in early childhood or adolescence, and these children, uh, when they have these, uh, severe symptoms, uh, tend to avoid handshakes, they have difficulty with sports, uh, they're Playing musical instrument is difficult and uh uh when they take examination, it uh hampers their um their performance. Uh, in general, they tend to avoid social contact because of their underlying problem. And, uh, um, and many patients and families do not know that there are effective treatment for hyperidrosis. And so the pediatricians are often the first clinicians who could, uh, give the name to the problem and then actually start the treatment. So typical patients you might see are, for example, for parma hyperdosis, you might see a 15 year old who comes in and um who who um avoids handshakes and has difficulties with the uh when taking examinations. And uh uh when taking examination, their hands may drip and cause papers to become really uh wet, uh, and then, um, typically they say that the symptoms started very early. Another, uh, patient is a, uh, might be a 13 year old, uh, who, uh, uh, who has axillary, uh, hyperhidrosis, and then these patients, because of their profuse sweating, they have to change their shirts, uh, frequently. Um, they use deodorants, um, and they tend to also, uh, become embarrassed because of their, um, uh, the sweating problem. Now there's also a third category of these uh Patients with uh hyperhidrosis where it's excessive sweating, these are, uh, maybe, uh, a new, uh, generalized night sweating. They may have weight loss, fevers, uh, they may have some medication start that started or, um. So these are something that you have to look out for uh when um when looking at patients with hyperidosis. So the definition of hyperjosis is a uh sweating beyond its uh physiologic need. So, um, clinical definition is that it causes difficulty in daily life that exceeds what is needed to maintain normal body temperature. Objectively, if you were to define it, um, you would typically what you have to do is you have to collect the sweat, uh, so, uh, from the skin, and if it's more than 100 mg per sweat per centimeter square per minute collection, then that defines hyperedrosis. But basically in practice, the functional impairment matters more than the sweat measurements, so we rely on the clinical definition to diagnose the problem. So, um, when seeing a patient with hyperjosis, uh, you want to ask, uh, these, uh, set of questions that might help you, um, diagnose the problem. So the first question might be, when did it start? And the typical answer is, uh, it started, um, very early. And where is the sweating? And, uh, um, and the answer is, uh, it typically is focal, it's bilateral, uh, it's, uh, it's defined to the sweat, um, defined to the palms. The plantar area and axilla. And uh uh does it stop during sleeping hours? And yes, uh, typically primary hyperjosis usually does not occur during sleep. Uh And uh what are the problems that cause the, the, that cause the difficulties? Uh, the patients will typically say it causes uh difficulties with writing, uh, and sports, uh, playing music, and have social uh um contact, um, anxieties. Um, now, if the patient, however, says, um, uh, this is something that started, uh, suddenly out of the blue, uh, recently, or, uh, it's, uh, generalized, or, um, Uh, it's related to, uh, possibly with weight loss, then you have to think about, uh, other secondary causes. So, um, hyperidrosis, there's primary and secondary. So the primary, uh, hyperidrosis is localized, uh, hyperidrosis, meaning to the hands, the feet, and axilla, and it's also, uh, usually, uh, worsened by stress or heat. And then typically there's a family history of hyperidrosis. Secondary, um, hyperidrosis is generalized, meaning that it affects the entire body. Um, you may have to think about, um, thyroid disease or infections or, uh, possibly malignant malignancies. Uh, it could be due, due to, uh, medications such as using beta-blockers or antidepressants. Uh, other, uh, not so much related to children, but, uh, think about pregnancy or, or, uh, anxiety disorders. So the red flags, uh, when seeing a patient with hyperrorosis is, as I mentioned, uh, if it's generalized, then it's not primary hyperrorosis, you have to, uh, dig into other causes, um, weight loss or fatigue, or palpitation, uh, or another set of, uh, red flags. And uh uh um. When you suspect that patient might have, um, hyperthyroidism, then you want to check the TSH or T4 level and then doing blood tests will be, um, Uh, done selectively, uh, not just for, um, For the, just the sake of doing a study, uh, to, uh, to see whether the electrolytes are OK. So, uh, parma hyperroidrosis, um, usually goes along with the plantar hyperroidrosis. They usually tend to go along together and, uh, they, uh, range from unpleasant moisture to profuse dripping, and, uh, um, oftentimes it's triggered by heat or emotional stress, and, uh, also just out of the blue, uh, just without any cause. And, uh, uh, tends to, um, get better, uh, during wintertime when it's colder. And then during summertime it tends to be worse. So primary hyperrorosis is the most clinical, uh, primary hyperrorosis. It's the most distressing form for patients. Uh, it actually, um, it's, uh, it's a, uh, form of, uh, uh, problem that actually limits your, uh, could limit your, uh, profession because, and this is a big deal in that, um, having this problem could actually change what you do for the rest of your life because, uh, Of, uh, difficulty with handling materials because of sweating, um, uh, for example, handling with papers and then, uh, interacting socially. So a child may decide, oh, this is just too stressful, and, and they decide may, you know, this, they're not gonna do become a doctor or, or lawyer, for example, uh because uh this is too stressful to deal with socially because of the sweating palm. Uh, there's typically there is a fam uh familiar, uh, history of heparosis and, and the, uh, Uh, we also typically think about hyperrosis as a passing off as an autosomal dominant transmission. It's not always autosomal dominant, but, uh, typically tends to, um, it's transmitted in that fashion. So there's about 25% of families have excessive sweating and patients present with hyperrosis. In general, about 1% of the population suffer from sweaty palms, and of these, about 10 to 20% or 0.2% of the population have severe severe hyperrosis. So 0.2% seems like a low number, but it's actually, that's a significant number. So, uh, when you want to grade, uh, the hyperhidrosis, um, there's a simple, um, scale that you could use. Um, it's called the hyperhidrosis disease spirit scale, uh, scale 1234. So scale 1, it would be, um, amount of sweating that's not really that noticeable. It doesn't really interfere with daily life. Uh, scale 2, level 2 might mean, uh, it sometimes interferes. And then, um, level 3, it's frequently interferes and then level 4 is always interfering and it's uh constantly a constant problem. So typically for, um, for patients who are surgical candidates, these are patients who are either class 3 or or stage 3 or stage 4 patients. So treating, when treating the hyper drosis, there's a, there's a latter approach. We use a latter approach, and the first therapy that you would, uh, uh, might, um, prescribe, and you could actually, uh, prescribe this, you don't have to refer the patient to dermatology. Uh, you could prescribe these medications. You're perfectly allowed to do it. And the first therapy is to do, to use aluminum chloride solution, and the typical, uh, brand name, um, agent is called Drysol. It has aluminum chloride, and the way it works is that the aluminum chloride ion, when it goes into the pore of the, uh, sweat gland, it, uh, attaches to the mucus polysaccharides and then it precipitates and forming a gel, so in effect becomes a plug that forms in the sweat gland, uh, that prevents the sweat from coming out. Um, second, um, Therapy is ionthophoresis, and this is a applying direct current, uh, not alternating current, but direct current, uh, to the palm, and then this alters the, the, the neuronal signals that, uh, that's, uh, uh, that's applied to the, the sweat glands. The third, uh, approach is to use, um, oral anticholinergic, uh, is to, uh, basically block the sympathetic, um, neurotransmitters that, uh, regulate the sweat gland and then hence, uh, decrease the sweating. And the last option is to, uh, to do surgery and, uh, this is, um, uh, typically, um, reserved for patients who have severe, uh, hyperjosis who, uh, fail or cannot deal with, uh, medical therapy. So, the aluminum chloride is the first line therapy, uh, so you apply this at nighttime, uh, when the sweating is not present. Uh, it, uh, it may cause a skin irritation or thickening when it's, uh, used for a long time. Um, the second one is ionophoresis. Uh, this, uh, this one here, you can see this patient applying the, the hand to, uh, to this machine here. It applies a direct current to the, uh, palm, um, and, uh, um, this, uh, this, you could prescribe this, uh, um, device. Uh, there are different brands and, uh, um, Uh, once you write a prescription for the patient, they could go online to and, and, uh, purchase these, uh, devices. So, uh, when applying the aluminum chloride, uh, you, um, uh, uh, direct the patient to apply to the, to a dry skin, a dry palm, and then you wash it off in the morning, um, and the patient might, uh, use it every night for one, you know, for a week. And after you use it for a week, the uh, the hands become dry, and, uh, um, most times you actually the hand will be dry for a month. And then, uh, the patient will, after a month, uh, the pores will open up and then the patient will start to sweat and then the patient does it again. Uh, you could also do kind of a maintenance therapy. Uh, once the hand is dry, you use it like once or twice a week to kind of maintain it instead of waiting for, um, the pores to open up again and then you have to do the week, uh, 7 day course of doing the application. Um Sometimes when applying this, it may cause irritation because the, the patient is applying uh onto the skin which is damp. Uh, so it might be a good idea to dry the skin by applying, uh, using a dryer. Um. And initially, you have to, you have to tell the patients that it takes time for this to work. Uh, so if they just try it for like 1 or 2 days and then expect it to work, it's, uh, then they're gonna give up. So, uh, you have to warn them that they have to do it for a period of time and then have to have a schedule to use it, uh, regularly to, uh, to have the good effect. So ionophoresis is, is best suited for hands and feet, um. This works, uh, in a different way compared to the, to the, uh, Drysol. And, uh, uh, typically what you do is you, uh, you use the machine, um, once a day, uh, for about 30 minutes, and then after a week of use, your hand or the feet will become dry. And then similar to, uh, the Drysol, uh, you're, you know, you won't sweat for, for about a month. And then, um, Then the The, the sweat glands, uh, then they recover from the, the shock that they had and then it starts to sweat again. Then you have to uh use the, um, the machine again. The second line therapy is an oral anticholinergic, and the most commonly used medication is glycopyrrolate. That, I'm sure that you may have used this for some patients who drool a lot or they, uh, they have a lot of oral secretions, and, uh, typically this is, uh, started at one or two mgs once or twice a day, uh, or, and then you have to titrate it because, uh, The amount that the patient needs, uh, that to cause the effect, to have an effect may, may be bearable. Um, so you titrate the, the drug. Um, the second drug is, uh, it's called oxybutynin, and, uh, oxybutynin, it was originally used for, um, uh, overactive, uh, bladder, but it was found that it actually works also for hyperhidrosis, and, uh, so this has also become a second, um, Drug to use for hyperjosis. Now there, there's an extended release form which uh seems to um have a less of a side effect. So when using these anticholinergic, uh, because they are anticholinergic, you have to counsel the, uh, the patient about um dry mouth, uh, because basically it's drying out the body, uh, may cause constipation or blurred vision or urinary retention or it might have sometimes some cognitive effects. But the main, main complication is uh dry mouth. So, um, you have to use this, um, um, in a thoughtful manner, um, and, uh, you could actually also use the anticholinergic for situational use, meaning that when they really need to use the, uh, they have to stop sweating, for example, when they have to do some examination or performance, you could actually use these for temporary uh blockage of the, the sweating. Um, now, for certain patients who are, like, for example, athletes, uh, who, who, uh, sweat a lot and, and not, not sweat a lot because they have, they're sweating because they're doing exercise, uh, this may impair their sweating, so which could increase the, um, chances of heat stroke. So you have to warn them about, um, about that. Now, axillary hyperhydrosis, uh, use slightly different tools than parahydrosis, but it's almost the same. Uh, the first line therapy is the aluminum chloride, the solution, and then, uh, second line, there's actually, uh, a, um, topical anticholinergic. There are 22 brands. Um, they're both FDA approved. Uh, one is uh Cabrexa and the second one is Softtra. Uh, Cabrexa is a, um, it's a, um, Topical anticholinergic that's uh put on a cloth, so you, uh, wipe the axilla once a day with this cloth, uh, and then, uh, soft dry is a gel that you apply to the axilla. Uh, this, these anticholinergics are not uh FDA approved for the palm, it's only approved for the axilla. You could also take, um, oral, uh, anticholinergic similar to the parma hyperjosis, and then for the, uh, for the axilla, you could also do, uh, botulinum, botulinum ectoxin injection. And, uh, this, uh, when you apply to the axilla, this would work for 6 months, but then, uh, the toxin effect will be gone after 6 months, then you have to do it again. Uh, you could do toxin, uh, injection to the palm, but, uh, this is very painful, so this is hard, rarely done for pediatric patients. And uh fourthly and fifthly, um, uh, treatment is a surgical treatment, and this is a permanent cure, meaning that once you do this operation, your axilla will not uh sweat indefinitely. So, and uh doing this operation, uh, you target. Either T4 or T2 ganglion and similar to the hand operation, uh, this is a permanent cure. Um, again, I mentioned that the botulum botulum toxin could be used for axillary sweating, and there's a another, um, um, uh, method, uh, that is to use a microwave, um, uh, heating of the sweat gland, and there's an FDA approved, uh, device called MiraDry, uh, which is used to, um, basically, uh, heat the, um. The sweat glands and then um It, this also works uh pretty well for, um, it's, it's also a permanent uh uh cure for axillary sweating. But this is not approved for the palm, it's only approved for um the axilla. So when to refer the patient, um, Uh, for patients with palm and axillary sweating, um, when these things, these conditions, uh, interfere with their schoolwork, they're, uh, affecting their, uh, sports activities, and then the anxieties that come about from social interactions, I think these patients are, should be treated, uh, because I should press treated surgically because other therapies, I think is, is temporary and, um. But, uh, and, but the surgical, uh, treatment is, is permanent and is, um, So, however, if the patient is not affected by so much by these uh thing and they, they're, you know, they're able to live out their life without anxiety or too much disabilities, then then obviously um the they could continue the medical therapy and then the surgery would not be um uh undertaken. So the practical question is, um, Uh, is the sweating affecting their life really badly? And if that's the case, then I think they should be referred, uh, because doing the operation will change their life in a positive manner. So here's some checklists for um Uh, when to refer or when think about thinking about, uh, referring the patient, so you wanna know that the, you're referring the patient for, uh, focal disease, meaning that it's for the palm or the hands, um, not for generalized sweating, uh, that they have a severe condition and they've tried, uh, some medical therapy and it's, it's not, uh, it's not the way to go for them. And then they don't have other problems that may be mimicking hyperidosis. So when patients come to a surgery, what are we trying to do? Uh, so the, the sweat glands is regulated only by the sympathetic innervation. There's no parasympathetic innervation to the sweat glands. So the sympathetic signal is the only thing that controls the sweat gland function. So the aim is to decrease the signal to the sweat gland that comes from the brain. Um So the way we do the operation at UCSF is we target the T3 ganglion and then uh in the process, uh, we don't injure uh other ganglion that uh is not needed to uh to be um. Um, injured, otherwise, uh, you may get complications. So, uh, when explaining, um, the, this operation, it's, it's also called the ETS or endoscopic thoracic sympathectomy. Uh, the, some questions that the patients might have, uh, or that like to, that I try to explain is the sweat sweat glands are actually normal, and it's due to the, the problem is due to the overactive nerve signals that come from the brain. And uh and the uh the aim of the operation is to, to decrease the signals that goes to the palms that cause the sweating. And uh uh and the the family might say, um, will the hands be dry, uh, when will, when will the hands become dry? The, as soon as you cut the nerve, uh, the T3 ganglion, that instantaneously the patient becomes dry. Uh, will the sweating move somewhere else? Uh, yes, it could move to somewhere else if there's a complication. Uh, can the children return to school and sports? They could return to school and sports, um, very quickly, like after 1 or 2 days. And, uh, and I explained to them that we use a technique that seems to, uh, optimize the result. Which I'm gonna talk about next. So here's the uh uh sympathetic uh uh map uh where the signal comes from. The signal comes from the hypothalamus. It comes down the spinal cord to the level of the T1 uh vertebra, and then uh from T1 to T2 and T3, T4, they, the signal goes to the intercostal nerve, and the nerve jumps off. The intercostal nerve to the right ramus, and then right from the right ramus, it enters the sympathetic trunk, which is shown here. A sympathetic trunk is a straight, uh, nerve that goes from the top of the chest all the way down to the, uh, to the pelvis, and, uh, um. And once the signal comes off the intercostal nerve, the T4, T3, T2, and T1 ganglion, these are the centers, postsynaptic centers where the sympathetic signals go. They go from T4, T3, T2, and T1. From T1, it goes onto the, then it goes to the arm, and then it innervates the palm. So, if we knock off, for example, the T3 signal, T3 ganglion, then the signals from T4 and T3 are blocked, but you still have a signal from T1 and T2. So you do maintain some signal, uh, to the, um, to the pump, and, uh, and you basically decrease 50% of the signal, which is the right amount, which we think, uh, which we, uh, that's going to, uh, have a good effect. That is to decrease your sweating and then at the same time um actually prevent a secondary problem which is compulsory sweating. So this compulsory sweating is the, um, it happens, or this only happens after a surgical treatment. So, um, This is an increased sweating in areas that were previously not sweating. I mean, you do sweat in other parts of the body, so, but after when you develop compulsory sweating, you're sweating profusely in other places that you have no control or or um there is a degree of compulsory sweating in that some patients um um they only sweats a little bit more when they exercise. Uh, the common locations are trunk, uh, back, abdomen, and lower extremities. Uh, when they do occur, however, sometimes they do get, tend to get better over time, but, uh, some, uh, small number of patients that this may persist and, and, uh, um, So you're basically exchanging your hand sweating to uh some other areas. Your hands won't sweat, but your other areas are sweating similar to like hands. So how do we gonna, how do we gonna prevent this compensory sweating complications? So, uh, so the method that we've come up with is to, um, to target the T3 ganglion but not and not injure the T2 ganglion. So, um, typically, uh, uh, in, in Most of the surgical arena, there's so many ways to do this operation. So about 10 or 15 years ago, the Society of Thoracic Surgery, they put out a white paper which they described after reviewing like 10,000 papers. How to do the operation. So they recommended to cut the sympathetic trunk at the rib 3 level. Just simply cut it at the rib 3 level. And despite that recommendation, the compulsory sweating rate, however, has not decreased over the years. We also did a 40 cadaver um dissection research to identify where the rib, I'm sorry, the T2 ganglion is located. And uh so this is the result, uh, we see that the T2 ganglion is distributed above the rib 3 as expected, but actually about 40% of the time, the T2 ganglion overlies the rib 3. So when the surgeon is cutting the, the rib 3, you accidentally burn the T2 or the harm the T2, and then, uh, we know that based on other, um, Surgical techniques that we do when injuring the T2 ganglion, if you specifically injure the T2 ganglion, up to 70 70% of the time, you will get compulsory sweating. So if the patient is unlucky, the patient will get compulsory sweating, and then if the patient is uh like it's like a 50/50 chance almost um of getting a compulsory sweating versus not. So this is the reason why we don't do the rib 3, but uh we target the T3 precisely by following the, the white ramus. So the uh simplified idea is find the intercostal nerve 3, find the white ramus, and then uh once you find the T3, you selectively knock out the T3 and avoid the T2 ganglion. So, so far, um, we published a paper where we, uh, did, uh, we're up to about 80 patients now where, uh, we use this T3 ganglion ganglionectomy method and, uh, uh, we have had very good result. 100% of the patients have been satisfied with the outcome, meaning that they're happy with the hands not sweating. And uh um up until only like a few uh 1 month ago, we had basically zero compensory sweating, but uh we had recently one patient that developed compensory sweating and uh um So, um, It's not a perfect method, but, uh, this is, uh, better than any, uh, report, um, that's out there because in the literature, the compulsory sweating rate is about 20 to 50% and, uh, and then our result is close to 1% or less than that. So postoperatively, um, the, you expect, uh, uh, we, when we see the patient, um, we inquire about the hands, which, uh, Typically, I would say it's dry and, uh, um, sometimes, however, they do have some chest pain or shoulder pain after the operation, which, uh, may last about a week, but most patients are, um, do not have the symptoms. And, uh, um, And we ask about compensory sweating, which uh tends to occur within the first month of the operation. So once you're past the first month, um, chances of getting compensory sweating uh goes down to um Very close to 0. So, uh, when counseling the families, uh, with the operation and the treatment, uh, you have to set expectations, um, that, um, Uh, the surgery will, uh, provide, uh, durable, uh, relief and essentially a cure for the problem. Uh, but, um, there are alternatives to the operations that we talked about, uh, and there is still a small risk of getting compulsory sweating, and And because we don't know everything that there is no, uh, no, there is about the sympathetic system and why the sympathetic, uh, compensory sweating occurs, uh, there is a small chance that you could get compensory sweating. I can't say it's zero, and, uh, um. It's a, there's a small risk. Um OK, um. So the take home message is that uh primary primary and uh axillary axillary hyperjosis, the is, is a uh is a quality of life condition and uh uh the pediatrician could diagnose it. uh, they could rule out the secondary causes and they could initiate the treatment. Um, you don't have to ask the dermatologist to treat it, you could do it. It's, uh, it's all FDA approved, uh, medications and, and, uh, um. Uh, and, and, uh, devices. Um, when the, uh, the condition is severe, I think, uh, they should be, um, uh, referred for a surgical consultation because although there's risk, uh, the patients, uh, in general have, uh, good outcomes and they're very happy and, and affects their, um, their outlook and their life, uh, going. Uh, then definitely, basically. Uh, and then, um, When we do do the operation, the, hopefully, the other, other surgeons will pick up on this uh paper that we wrote that we should do a T3 ganglionectomy and not do um the rib uh 3 sympathectomy that uh most uh surgeons are doing these days. Uh, here's some uh references that, um, that I used to, for the talk. Uh, this concludes the talk. Created by Related Presenters Sunghoon Kim, MD Pediatric and trauma surgeon View Full Profile
