Manejo médico de la hiperhidrosis / Medical management of hyperhidrosis

La hiperhidrosis es un aumento patológico de la sudoración, que puede asociarse a patologías médicas y fármacos, afectando en forma significativa la calidad de vida. La hiperhidrosis focal primaria es una patología común, cuyo manejo es un desafío. Están disponibles múltiples terapias para el tratamiento de hiperhidrosis, incluyendo productos tópicos, iontoforesis, toxina botulínica, fármacos sistémicos, cirugía y nuevos equipos para destrucción selectiva de las glándulas sudoríparas. El propósito de este artículo es revisar la literatura, enfocándose en las terapias no quirúrgicas y opciones de tratamiento emergentes.

Hyperhidrosis is a pathological excessive sweating. It can be associated with medical conditions or drugs and affect significantly the quality of life. Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. Multiple therapies are available for the treatment of hyperhidrosis, including topical products, iontophoresis, botulinum toxin, systemic medications, surgery and new devices aimed at the destruction of ecrine glands. The purpose of this article is to review the literature, with a focus on non-surgical therapies and emerging treatment options.

Macular atrophy after combined intravitreal triamcinolone and photodynamic therapy to treat choroidal neovascularization.

AIM: To report the appearance of choriocapillaris atrophy after combined high dose intravitreal triamcinolone acetonide (TA) and photodynamic therapy (PDT) to treat choroidal neovascularization (CNV) associated with age related macular degeneration (AMD). METHODS: The present study was retrospective about non-randomized interventional case series. Fifty-one consecutive eyes with subfoveal (all types) CNV associated with AMD were treated by PDT and intravitreal (19.4±2.1)mg per 0.1mL TA at the Alicante Institute of Ophthalmology. The appearance of macular choriocapillaris and retinal pigment epithelium (RPE) atrophy was considered at two years follow-up. Thirty consecutive eyes treated by PDT alone, matched for age, sex, and type and size of CNV were considered as control group. RESULTS: Twenty-one of 47 eyes in the study group (45%) and 7 of 30 eyes in the control group (23%) developed macular RPE and choriocapillaris atrophy in the treated area at month 24 (P=0.04, Chi-square test). The greatest diameter of the atrophic areas averaged (5044±1666)µm in the study group vs (4345±1550)µm in the control group. Mean final best corrected visual acuity (logarithm of minimal angle of resolution) was (0.87±0.33) in the cases with RPE atrophy vs (0.66±0.26) in the cases with no RPE atrophy in the study group (P=0.11, Mann-Whitney U test). CONCLUSION: The association of high doses of intravitreal TA and PDT may increase the risk for RPE and choriocapillaris atrophy.

Secondary elevated IOP and cataracts after high-dose intravitreal triamcinolone and photodynamic therapy to treat choroidal neovascularization.

PURPOSE: To analyze the appearance and evolution of high intraocular pressure (IOP) and cataracts after high-dose intravitreous triamcinolone acetonide (TA) and photodynamic therapy (PDT) to treat choroidal neovascularization associated with age-related macular degeneration. PATIENTS AND METHODS: Retrospective, consecutive, nonrandomized, interventional case series. Fifty-one consecutive eyes with subfoveal (all types) choroidal neovascularization associated to age-related macular degeneration were treated by PDT and intravitreal 19.4+/-2.1 mg/0.1 mL TA. Changes in IOP and lens were considered as primary outcome indicators. Optic disk changes were also considered. RESULTS: Twenty nine of 49 eyes (59%) needed topical therapy for high IOP at month 12, and 11 of 47 (23%) at month 24. Cataracts appeared in 14 of 42 phakic eyes (33%) after 12 months follow-up and in 22 of 40 phakic eyes (55%) completing 24 months follow-up. One eye showed an increased cup-to-disk ratio. CONCLUSIONS: The use of high-dose intravitreal TA is associated with cataracts and IOP elevation in approximately 50% of cases. The need for topical treatment for high IOP decreases during the second year.

Hypothalamic tanycytes: a key component of brain-endocrine interaction.

Tanycytes are bipolar cells bridging the cerebrospinal fluid (CSF) to the portal capillaries and may link the CSF to neuroendocrine events. During the perinatal period a subpopulation of radial glial cells differentiates into tanycytes, a cell lineage sharing some properties with astrocytes and the radial glia, but displaying unique and distinct morphological, molecular, and functional characteristics. Four populations of tanycytes, alpha(1,2) and beta(1,2), can be distinguished. These subtypes express differentially important functional molecules, such as glucose and glutamate transporters; a series of receptors for neuropeptide and peripheral hormones; secretory molecules such as transforming growth factors, prostaglandin E(2), and the specific protein P85; and proteins of the endocytic pathways. This results in functional differences between the four subtypes of tanycytes. Thus, alpha(1,2) tanycytes do not have barrier properties, whereas beta(1,2) tanycytes do. Different types of tanycytes use different mechanisms to internalize and transport cargo molecules; compounds internalized via a clathrin-dependent endocytosis would only enter tanycytes from the CSF. There are also differences in the neuron-tanycyte relationships; beta(1,2) tanycytes are innervated by peptidergic and aminergic neurons, but alpha(1,2) tanycytes are not. Important aspects of the neuron-beta(1) tanycyte relationships have been elucidated. Tanycytes can participate in the release of gonadotropin-releasing hormone (GnRH) to the portal blood by expressing estrogen receptors, absorbing molecules from the CSF, and providing signal(s) to the GnRH neurons. Removal of tanycytes prevents the pulse of GnRH release into the portal blood, the peak of luteinizing hormone, and ovulation. The discovery in tanycytes of new functional molecules is opening a new field of research. Thus, thyroxine deiodinase type II, an enzyme generating triiodothyronine (T(3)) from thyroxine, appears to be exclusively expressed by tanycytes, suggesting that these cells are the main source of brain T(3). Glucose transporter-2 (GLUT-2), a low-affinity transporter of glucose and fructose, and ATP-sensitive K(+) channels are expressed by tanycytes, suggesting that they may sense CSF glucose concentrations.

Polarized endocytosis and transcytosis in the hypothalamic tanycytes of the rat.

Four types of tanycytes can be distinguished in the rat hypothalamus: alpha(1) and alpha(2) tanycytes establish an anatomical link between the ventricular cerebrospinal fluid (CSF) and the arcuate nucleus, whereas beta(1) and beta2 tanycytes establish a link between CSF and portal blood. Endocytosis and transcytosis in these cells have been investigated by (1) immunocytochemistry with antibodies against molecular markers of the endocytotic and transcytotic pathways; (2) the administration of wheat germ agglutinin (WGA) into the ventricular or subarachnoidal CSF and following its internalisation by and its routing through tanycytes. The four populations of tanycytes show marked differences concerning the expression and subcellular location of proteins involved in endocytosis and transcytosis, such as clathrin, caveolin-1, Rab4 and ARF6. Thus, beta1,2 tanycytes express caveolin-1 at the ventricular cell pole and at their terminals contacting the portal capillaries, whereas alpha1,2 tanycytes do not, suggesting that caveolae-dependant endocytosis does not occur in the latter and that, in beta1,2 tanycytes, it may occur at both cell poles. In beta1,2 tanycytes, clathrin is only expressed at the ventricular cell pole indicating that clathrin-dependant endocytosis operates for compounds present in the ventricular CSF and not for those exposed to the terminals. This agrees with the property of beta1,2 tanycytes of internalising WGA through the ventricular cell pole but not through the terminals. The subcellular distribution in beta1,2 tanycytes of WGA and of the proteins clathrin and Rab4 indicates that part of the internalised WGA follows the degradative pathway and part is sorted to a transcytotic pathway and that the transcytotic and the secretory pathways might intersect.

Antibodies obtained by xenotransplantation of organ-cultured median eminence specifically recognize hypothalamic tanycytes.

Tanycytes are specialized ependymal cells lining the infundibular recess of the third ventricle of the cerebrum. Early and recent investigations involve tanycytes in the mechanism of gonadotropin-releasing hormone (GnRH) release to the portal blood. The present investigation was performed to obtain a specific immunological marker of tanycytes and to identify the compound(s) responsible for this labeling. After 30 days of organ culture, explants of bovine median eminence formed spherical structures mostly constituted by tanycytes. These tanycyte spheres were xenotransplanted to rats, and the antibodies raised by the host animals against the transplanted living tanycytes were used for immunochemical studies of the bovine and rat median eminence. This antiserum immunoreacted with two compounds of 60 kDa and 85 kDa present in extracts of bovine and rat median eminence. The individual immunoblotting analysis of rat medial basal hypothalami showed a decrease in the amount of the 85-kDa compound in castrated rats as compared to control rats processed at oestrus and dioestrus. The antiserum, labeled as anti-P85, when used for immunostaining of sections throughout the rat central nervous system, immunoreacted specifically with the hypothalamic tanycytes. Within tanycytes, P-85 immunoreactivity was exclusively present in the basal processes. It is suggested that the 85-kDa and 60-kDa compounds correspond to two novel proteins selectively expressed by tanycytes. The possibility that they are secretory proteins involved in GnRH release is discussed. Anti-P85 appears to be the first specific marker of hypothalamic tanycytes.