Thoracic sympathectomy for the treatment of primary axillary hyperhidrosis: systematic review and proportional meta-analysis.

INTRODUCTION: Primary hyperhidrosis is a disorder that involves excessive sweat production, which has a negative impact on the quality of life. OBJECTIVE: To evaluate the effectiveness and safety of video-assisted thoracoscopic sympathectomy (VATS) for treating primary axillary hyperhidrosis (PAH) and determine which level of ganglion resection offers the best outcome. METHOD: This was a systematic review and proportional meta-analysis of observational studies. The result was evaluated for satisfaction, control of symptoms, compensatory sweating and complications. A subgroup analysis was performed to compare the sympathetic trunk resection at high and low levels. RESULTS: Thirteen studies were selected with a total of 1463 patients. The satisfaction rate was 92% (95% CI = 88-95%, I2=47.5%), the symptom control rate was 96% (95% CI = 93-99%, I2=48.2%), and the presence of compensatory sweating could not be assessed because of high heterogeneity among studies. The complications were rare. CONCLUSION: This review demonstrated that thoracic sympathectomy by VATS is a viable and safe option for the treatment of PAH. There was no difference between high and lower levels of resection. However, the estimation of the effect is quite uncertain because the quality of evidence was extremely low.Key messagePure axillary hyperhidrosis has great potential to compromise quality of life.Surgery should be indicated only when clinical treatment fails.Thoracic sympathectomy by video-assisted thoracoscopy is a viable and safe option for the treatment of primary axillary hyperhidrosis.

Management of Primary Focal Hyperhidrosis: An Algorithmic Approach.

Hyperhidrosis (HH) is defined as perspiration beyond the level required to maintain temperature regulation. HH affects nearly 4.8% of the population in the United States. It can have a great impact on patient’s quality of life by disturbing daily activity, performance, confidence, social interactions, and mental health. In the majority of patients with HH (93%), the etiology of excess sweating is idiopathic, which classifies it as primary focal HH. Mild HH may be controlled with topical antiperspirants and lifestyle modifications. Based on the location of involvement, iontophoresis and botulinum toxin may be considered if the patient does not respond to topical therapies. Despite minimizing sweating, chronic use of systemic anticholinergics, in particular oxybutynin, may result in detrimental adverse effects such as dementia. Local surgery, radiofrequency, microwave, and lasers are other potential modalities for HH. Sympathectomy can be a last resort for the treatment of focal HH of the palmar, plantar, axillary, and craniofacial areas after failure of less invasive therapeutic options. In this review, we conducted a comprehensive search in the PubMed electronic database to summarize an algorithmic approach for the treatment of HH. This can help broaden options for managing this difficult disease. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5774.

Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax): Evaluation of Measurement Performance.

BACKGROUND: Clinical trials of primary axillary hyperhidrosis (AHH) require rigorous measurement of AHH severity from the patient’s perspective. Previously, we reported conceptualization and item content development for the Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax) scale. OBJECTIVE: To evaluate the psychometric performance and estimate clinically meaningful change scores for the HDSM-Ax in a Phase IIb clinical study of sofpironium bromide gel for AHH. METHOD: HDSM-Ax measurement performance was analyzed in trial response data using two psychometric paradigms: Classical Test and Rasch Measurement Theories (CTT; RMT). HDSM-Ax meaningful change scores were estimated from anchor-based methods using two global summary questions of hyperhidrosis severity and the Hyperhidrosis Disease Severity Score (HDSS). RESULTS: HDSM-Ax satisfied CTT and RMT criteria as a fit-for-purpose outcome measure in AHH clinical trials. Within-person anchor-based analyses indicated a 1-point change in HDSM-Ax severity score (range, 0–4) represents a clinically meaningful change in AHH severity. CONCLUSION: HDSM-Ax is a well-defined and reliable measure of AHH severity. A 1-point change in HDSM-Ax score is clinically meaningful. J Drugs Dermatol.20(4):410-418. doi:10.36849/JDD.5569.

Bilateral one-stage single-port sympathicotomy in primary focal hyperhidrosis, a prospective cohort study: treat earlier?

BACKGROUND: Primary Focal Hyperhidrosis (PFH) has a detrimental effect on Quality of Life. Repetitive, non-curative symptomatic strategies dominate current treatment of PFH, in spite of the availability of an effective and permanent curative treatment like Endoscopic Thoracic Sympathectomy (ETS). Current surgical optimization may allow for a re-established position of sympathetic modulation in this treatment algorithm. We sought to evaluate the safety, effectiveness, and long-term results of a Bilateral One-stage Single-port Sympathicotomy (BOSS) procedure in PFH patients and to identify subgroups benefitting most. METHODS: Prospective analysis of 163 patients, 35 (21.5%) underwent Rib-3 (R3) BOSS for palmar PFH, 58 (35.6%) R3-R5 BOSS for axillary PFH and 70 (42.9%) R3-R5 BOSS for combined palmar/axillary PFH. Effectiveness was measured using Skindex-29 and the Hyperhidrosis Disease Severity Scale (HDSS). RESULTS: Overall Skindex-29-rating (46.5 ± 14.8 preoperatively vs 20.1 ± 20.6 postoperatively, p < 0.001), and HDSS score (3.71 ± 0.45 preoperatively vs 1.82 ± 0.86 postoperatively, p < 0.001) indicated a significant improvement in health-related quality of life after BOSS. R3 BOSS was superior to R3-R5 BOSS in terms of HDSS score (1.49 vs 1.91 respectively, p = 0.004) and in terms of severe compensatory hyperhidrosis, a frequently reported side-effect (17.1% vs 32.8% respectively, p < 0.001). No major complications occurred. CONCLUSIONS: BOSS is safe, effective, and offers a long-term curative solution in the treatment of PFH. Especially in the palmar PFH subgroup, R3 BOSS treatment results compare favorably to the treatment results of non-curative alternatives published in the current literature. Therefore, R3 BOSS should be offered to all patients with severe PFH, reporting insufficient benefit of treatment options such as oral and/or local agents.

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada.

BACKGROUND: Psychodermatologic disorders are difficult to identify and treat. Knowledge about the prevalence of these conditions in dermatological practice in Canada is scarce. This hampers our ability to address potential gaps and establish optimal care pathways. OBJECTIVES: To provide an estimate of the frequencies of psychodermatologic conditions in dermatological practice in Alberta, Canada. METHODS: Two administrative provincial databases were used to estimate the prevalence of potential psychodermatological conditions in Alberta from 2014 to 2018. Province-wide dermatology claims data were examined to extract relevant International Classification of Disease codes as available. Claims were linked with pharmacy dispensation data to identify patients who received at least 1 psychoactive medication within 90 days of the dermatology claim. RESULTS: Of 243 963 patients identified, 28.6% had received at least 1 psychotropic medication (mean age: 47.9 years; 67.5% female). Rates of concurrent psychotropic medications were highest for pruritus and related conditions (46.7%), followed by urticaria (44.5%) and hyperhidrosis (32.8%). Among patients with psychotropic medications, rates of antidepressants were highest (56.3%), followed by anxiolytics (37.1%). Across billing codes, besides hyperhidrosis (71.2%), diseases of hair (61.4%) and psoriasis (59.1%) had the highest rates of antidepressant dispensations. Patients with atopic dermatitis had the highest rates for anxiolytic prescriptions (54.3%). CONCLUSION: In a 5-year window, more than a quarter of the identified dermatology patients in Alberta received at least 1 psychotropic medication, pointing to high rates of potential psychodermatologic conditions and/or concurrent mental health issues in dermatology. Diagnostic and care pathways should include a multidisciplinary approach to better identify and treat these conditions.

Anxiety and Depression in Primary Hyperhidrosis: An Observational Study of 95 Consecutive Swedish Outpatients.

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Bilateral R5-R8 sympathectomy for compensatory hyperhidrosis: complications and patient satisfaction. / Simpatectomia bilateral R5-R8 no tratamento de hiperidrose compensatória: análise de complicações e satisfação dos pacientes.

OBJECTIVE: The purpose of this study was to assess the quality of life of patients who had undergone bilateral thoracic sympathectomy from R5 to R8 as a treatment for severe and debilitating compensatory hyperhidrosis (CH). METHODS: Twelve patients with severe and debilitating compensatory hyperhidrosis underwent extended sympathectomy (R5-R8) from September 2016 to May 2019 at the Hospital das Clínicas, Federal University of Pernambuco, Brazil. Outcomes such as the level of patient satisfaction with the operation, quality of life scores as well as postoperative complications were assessed. RESULTS: There has been a substantial improvement in the quality of life score of 66% of the sample. In all four domains, a statistical significant difference was seen, regarding the relief of compensatory hyperhidrosis symptoms. CONCLUSIONS: Extended sympathectomy from R5 to R8 was shown to be quite effective in most cases, leading us to believe that this approach could be a therapeutic option for severe compensatory hyperhidrosis.

OBJETIVO: Avaliar a qualidade de vida de pacientes submetidos a simpatectomia torácica bilateral de R5 a R8 como forma de tratamento da hiperidrose compensatória (HC) grave e debilitante em pacientes que foram previamente submetidos a simpatectomia torácica bilateral para tratamento da hiperidrose localizada. MÉTODOS: Doze pacientes com hiperidrose compensatória grave e debilitante foram submetidos a simpatectomia estendida no Hospital das Clínicas da Universidade Federal de Pernambuco, Brasil, entre setembro de 2016 e maio de 2019. Os seguintes desfechos foram estudados: nível de satisfação com a operação, escore de qualidade de vida e as possíveis complicações cirúrgicas. RESULTADOS: Houve significativa melhora na qualidade de vida em 66% da amostra. Em todas as esferas de função, foi evidenciada relevância estatística no que se refere ao alívio dos sintomas relacionados à hiperidrose compensatória. CONCLUSÕES: A simpatectomia estendida de R5 a R8 mostrou-se efetiva na maioria dos casos operados, caracterizando este procedimento como promissor, podendo, após estudos futuros, ser incluído como uma opção terapêutica para a hiperidrose compensatória.

Quality of life after thoracic sympathectomy for palmar hyperhidrosis: a meta-analysis.

OBJECTIVE: Palmar hyperhidrosis affects 0.6-10% of the general population, having an important impact in patients' quality of life. The definitive treatment for palmar hyperhidrosis is thoracic sympathectomy. The purpose of this study is to evaluate the quality of life after thoracic sympathectomy for palmar hyperhidrosis. METHODS: The interest studies were searched in six comprehensive databases. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane system evaluation manual. Meta-analysis was performed with RevMan version 5.3. The outcome of interest was quality of life. The subgroup analysis and sensitive analysis were performed. RESULTS: Nine trials, including 895 patients, with accessible data comparing preoperative quality of life score with postoperative quality-of-life score were used for data analysis. Compared with preoperative quality-of-life score, application of thoracic sympathectomy improved the postoperative quality of life of palmar hyperhidrosis patients (MD = 57.81, 95% CI 53.33-62.30). Subgroup analysis of the different thoracic sympathectomy segment showed that there was no significant difference in the results obtained when operated with single segment or multiple segments (single segment: MD = 61.16, 95% CI [56.10, 66.22], multiple segments: MD = 52.14, 95% CI [48.39, 55.88]). CONCLUSION: The meta-analysis provided evidence of the improved quality of life after thoracic sympathectomy for palmar hyperhidrosis.

Long-term results of the treatment of primary hyperhidrosis with oxybutynin: follow-up of 1,658 cases.

BACKGROUND: Hyperhidrosis (HH) is characterized by exaggerated sweating in a specific region due to hyperfunction of the sweat glands. In the late 2000s, we started treating patients with an anticholinergic, oxybutynin, that was not being used until then. OBJECTIVES: To present, after 12 years of utilizing this medication in our service, the substantial experience obtained with the use of oxybutynin as an initial treatment of HH in a large series of 1,658 patients. METHODS: We analyzed 1,658 patients treated with oxybutynin for HH from May 2006 to June 2018. The patients were divided into four groups according to the main site of HH: the plantar group, the axillary group, the facial group, and the palmar group. To measure the degree of satisfaction, a quality of life (QoL) questionnaire was used. RESULTS: Pre-treatment QoL was poor or very poor in more than 94% of the cases, and the palmar group had the worst quality of life. After treatment, we observed an improvement in the quality of life in 77% of patients. More than 70% of the patients in all groups present moderate or optimal subjective clinical improvement in sweating after treatment. The group with the best result was the facial group. Intense dry mouth was reported in 24.9% of all patients in all groups. CONCLUSIONS: This study included a large number of patients followed for a long period and demonstrated the good effectiveness of treatment with oxybutynin for hyperhidrosis in the main sites of sweating.

Personality traits associated with blepharospasm: A comparison with healthy subjects, patients with facial hemispasm and patients with hyperhidrosis.

The aim of this study is to explore the existence of specific personality traits related to patients with blepharospasm (BSP), treated with injections of botulinum neurotoxin (BTX). Sixteen patients with BSP, 22 with facial hemispasm (HFS), 20 with essential hyperhidrosis (EH) and 20 healthy controls (HCs) completed the Temperament and Character Inventory-Revised to explore personality traits based on Cloninger's Psychobiological Model. The results revealed that the four groups differed on the Harm Avoidance (HA) scale and fear of uncertainty subscale, as well as on Persistence (PS). On HA, BSP group did not differ from HCs, but had higher scores than HFS and EH groups. On PS scales, BSP and HFS patients did not differ between them but showed higher score than HCs and EH patients. Our findings suggested that a high level of Harm Avoidance and Persistence seem to be associated with BSP, when compared with any disorders treated with BTX. An evaluation of the personality traits might help the clinicians to early identify BSP patients at greater risk of developing psychopathological disturbances.

Is there any relationship between quality of life and the level of sympathectomy in primary palmar hyperhidrosis? Single-center experience.

BACKGROUND: The discussions at the surgical levels (sympathectomy levels) about endoscopic thoracic sympathectomy (ETS) method, which is applied in hyperhidrosis treatment in the present day and acknowledged as the golden treatment method, continue. Mainly, most of the studies evaluates postoperative early period results. Our aim in this study is to compare the long-term quality of life depending on the different surgical levels (sympathectomy levels) and evaluate the postoperative complications. METHODS: 165 patients operated due to palmar hyperhidrosis between January 2012 and July 2017 were evaluated. Sympathectomy was performed either by clipping or cauterization and sympathetic nerves included were T2-4, T3-4, or T3 levels. Data were retrospectively reviewed for complications, factors affecting the postoperative quality of life. RESULTS: Ninety of the patients were male (54.5%) and 75 (45.5%) were female. The level of ganglion block was T2-T4 in 62 patients (37.6%), T3-T4 in 46 patients (27.9%), and T3 in 57 patients (34.5%). Early complications were observed in 27 patients (16.4%). Compensatory hyperhidrosis (CH) was observed in 62 patients (37.6%). There was a significant difference in the postoperative quality of life according to ETS level (p < 0.001). Patients who underwent T2-T4 sympathectomy had a lower quality of life than patients who underwent isolated T3 or T3-T4 sympathectomy. CONCLUSION: Based on our results, we recommend performing lower level resections to increase the long-term quality of life in palmar hyperhidrosis patients. The lower risk of CH and comparable quality of life suggest that T3 sympathectomy is more effective.

Impact of Video-Assisted Thoracoscopic Sympathectomy and Related Complications on Quality of Life According to the Level of Sympathectomy.

BACKGROUND: Primary hyperhidrosis is defined as excessive sweating of idiopathic etiology, associated with sympathetic hyperactivity, which greatly impacts patients' quality of life (QoL). The definitive treatment for palmar and axillary hyperhidrosis (PAH) is video-assisted thoracic sympathectomy (VATS). The objective of this study was to evaluate the quality of life of patients with PAH before and after VATS according to the level of sympathectomy performed, as well as the presence of compensatory hyperhidrosis (CH) and other complications. METHODS: All patients who underwent VATS in our vascular surgery department between January 2011 and December 2016 were included in the analysis. From 120 contact attempts, 88 interviews were carried out. Patients were divided into 2 groups according to the intervened thoracic level: high thoracic ganglion (HTG; T2, T2-T3, T2-T3-T4; n = 68) and low thoracic ganglion (LTG; T3, T3-T4, T4; n = 20). The questionnaire evaluated preoperative PAH severity, the presence of CH, preoperative and postoperative QoL, and postoperative satisfaction. RESULTS: The median age of patients was 29 years, and the median follow-up period was 32 months (IQR of 34 months). Most patients had severe or very severe PAH (97.7%) and preoperative QoL was bad or very bad (95.5%). Postoperatively, QoL was significantly improved in all domains evaluated, with no differences observed between the groups. The overall percentage of complications was 11.4%, mostly pneumothorax, but there was a significantly lower incidence of complications in the HTG group (P = 0.029). Compensatory hyperhidrosis developed in 85.2% of cases, but it was only considered intolerable in 10.2%. The incidence of CH was 82.4% in the HTG group and 95% in the LTG group, with no statistically significant differences between the groups (P = 0.147). CONCLUSIONS: Palmar and axillary hyperhidrosis severely affects QoL, and video-assisted thoracic sympathectomy was proven to be effective regardless of the target ganglion resected. Although CH was frequent, it was tolerated in most cases.

Effects of clipping endoscopic thoracal sympathectomy at Th4 on cardiopulmonary functions, quality of life and psychosocial functions.

BACKGROUND: In this study, we evaluated the cardiopulmonary and psychosocial effects of endoscopic thoracal sympathectomy (ETS) by clipping procedure at the level of Th4 and effects of ETS on quality of life of patients with hyperhidrosis. METHODS: We performed a prospective study in 52 patients complaining of local sweating who applied to our clinic. Cardiac maximal treadmill stress test (CMTST), pulmonary function tests, Beck anxiety-depression inventory, Liebowitz social anxiety scale and SF-36 quality of life questionnaires were administered at preoperative period and postoperative 6th month. RESULTS: In the pulmonary function test, we found a minimal decrease in FEV1, and FEV1/FVC. There were no significant change in 'resting pulse rate', 'resting systolic and diastolic blood pressures' during CMTST between before and after operation. There was a significant difference in peak heart rate before CMTST, post-exercise diastolic blood pressure, and age-predictive maximal heart rate between before and after clipping procedure. In the SF-36 questionnaire, all parameters were improved. In the Beck depression-anxiety inventory and the Liebowitz social anxiety scale significant improvement was achieved in all parameters. CONCLUSION: ETS by clipping procedure at the Th4 level is advised to be a safe and effective method for management of hyperhidrosis patients.

Simpatectomia bilateral R5-R8 no tratamento de hiperidrose compensatória: análise de complicações e satisfação dos pacientes / Bilateral R5-R8 sympathectomy for compensatory hyperhidrosis: complications and patient satisfaction

RESUMO Objetivo: Avaliar a qualidade de vida de pacientes submetidos a simpatectomia torácica bilateral de R5 a R8 como forma de tratamento da hiperidrose compensatória (HC) grave e debilitante em pacientes que foram previamente submetidos a simpatectomia torácica bilateral para tratamento da hiperidrose localizada. Métodos: Doze pacientes com hiperidrose compensatória grave e debilitante foram submetidos a simpatectomia estendida no Hospital das Clínicas da Universidade Federal de Pernambuco, Brasil, entre setembro de 2016 e maio de 2019. Os seguintes desfechos foram estudados: nível de satisfação com a operação, escore de qualidade de vida e as possíveis complicações cirúrgicas. Resultados: Houve significativa melhora na qualidade de vida em 66% da amostra. Em todas as esferas de função, foi evidenciada relevância estatística no que se refere ao alívio dos sintomas relacionados à hiperidrose compensatória. Conclusões: A simpatectomia estendida de R5 a R8 mostrou-se efetiva na maioria dos casos operados, caracterizando este procedimento como promissor, podendo, após estudos futuros, ser incluído como uma opção terapêutica para a hiperidrose compensatória.

ABSTRACT Objective: The purpose of this study was to assess the quality of life of patients who had undergone bilateral thoracic sympathectomy from R5 to R8 as a treatment for severe and debilitating compensatory hyperhidrosis (CH). Methods: Twelve patients with severe and debilitating compensatory hyperhidrosis underwent extended sympathectomy (R5-R8) from September 2016 to May 2019 at the Hospital das Clínicas, Federal University of Pernambuco, Brazil. Outcomes such as the level of patient satisfaction with the operation, quality of life scores as well as postoperative complications were assessed. Results: There has been a substantial improvement in the quality of life score of 66% of the sample. In all four domains, a statistical significant difference was seen, regarding the relief of compensatory hyperhidrosis symptoms. Conclusions: Extended sympathectomy from R5 to R8 was shown to be quite effective in most cases, leading us to believe that this approach could be a therapeutic option for severe compensatory hyperhidrosis.

The Meaning of Living for Men Suffering From Primary Hyperhidrosis.

Primary hyperhidrosis means excessive focal sweating and it has a negative effect on the mental health of those affected. Although there is no gender difference regarding the prevalence of the disease, men are less likely to seek help for this condition. The aim of this study was to explore the meaning of living with primary hyperhidrosis in men. Interviews with 15 men, selected by purposive sampling, were performed at Umeå University Hospital in Sweden between June 2016 and October 2017, and analyzed using qualitative content analysis technique according to Graneheim and Lundman (2004). This study found one theme, namely, to be captured in a filthy body, based on the categories: surrender to the condition reluctantly; prepare for a sweat attack; withdraw from close contacts; and worry about others' perceptions. The theme describes men living with hyperhidrosis feeling filthy while they struggle to control or hide the excessive sweating. Insufficient understanding from others and being reminded from the sweating is stressful and results in a sense of captivity. Interpreting the result, we conclude that the disease could stigmatize the individual, which has a negative effect on mental health and the will to seek help. Meanwhile, providing information about the disease early, as in schools, could increase the willingness of men to seek medical help. The results of this study also reinforce quantitative studies reporting the negative effects of primary hyperhidrosis on mental health.

A systematic review and meta-analysis to evaluate the efficacy of lumbar sympathectomy for plantar hyperhidrosis.

On July 25, 2017, we conducted an extensive database tracking to identify all studies published from January 1990 to July 2017. Screening updates were performed until December 2017. RESULTS: There were no deaths, and the resolution of symptoms of primary plantar hyperhidrosis (PPH) occurred in 92% of patients after mechanical sympathectomy. A total of 177 patients (44%) were reported to have mild to severe compensatory sweating after a mean 6 months follow-up. The preservation of L2 did not interfere with the primary outcome, and it is possible to perform lumbar sympathectomy in men with L2 preservation, achieving satisfactory cure results of PPH, minimizing the risk of sexual dysfunction. There were no deaths, and the resolution of symptoms of PPH occurred in 10% of patients after chemical sympathicolysis after a mean 6 months follow-up. A total of 13 patients (12.5%) were reported to have mild to severe compensatory sweating using the same technique. CONCLUSION: The mechanical lumbar sympathectomy is effective and safe and improves quality of life, evaluated by the high symptom resolution of PPH and low rate of complications. The chemical sympathicolysis in the immediate postoperative period presented satisfactory results; however, it was shown to be significantly less effective than the mechanical approach in a follow-up of at least 6 months.