Sweaty Palms_Dr Avinash Katara

SWEATY PALMS
What is sweating?
Sweating is an important bodily function that allows us to control our body
temperature and keep it within the normal range. We all sweat as a normal
response to different forms of stress (e.g. heat, exercise or emotional stress).
However, some people sweat excessively or disproportionately to such
stimulation.
What is Hyperhidrosis?
Hyperhidrosis is the excessive sweating produced by the body that is nonphysiological and disproportionate to that required for regulation of body heat.
It affects both sexes, all races and often has a family predisposition.
It occurs in about 1 in 20 people.
Hyperhidrosis can be of two types:
Generalized hyperhidrosis: excessive sweating all over the body
Focal (localized) hyperhidrosis: excessive sweating in a particular area of the
body e.g. palm of the hand, armpit, sole of the foot, face etc.
What are causes of Hyperhidrosis?
Hyperhidrosis can be primary (idiopathic; unexplained or unknown cause) or
secondary to other medical conditions.
Primary hyperhidrosis is a disposition, rather than a disease, of unknown
cause and affects approximately 1% to 2% of the population. In 40% of those
affected, there is a genetic predisposition.
Secondary hyperhidrosis can due to neurological, endocrine, metabolic,
infectious or malignant diseases, rugs, toxins etc. This is usually generalized all
over the body. Some of these common diseases are as follows:
Neurological: Parkinson’s disease, spinal cord injury, cerebrovascular accident
Endocrine: hyperthroidism, diabetes mellitus, hyperpituitarism, menopause
Neuroendocrine malignancy: pheochromocytoma, carcinoid tumor
Infections: tuberculosis, brucellosis
Toxic: alcoholism, substance abuse
Drugs: fluoxetine, venlafaxine, doxepin
What are diagnostic criteria for Primary Hyperhidrosis?
The person must have:
• focal visible excessive sweating
• for at least 6 months duration
• with no apparent cause.
In addition, he must fulfill 2 or more of the following criteria:
•
•
•
•
•
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Sweating should be bilateral and symmetric
Excessive sweating should cause impairment of daily activities
There should be at least one episode per week
The age of onset should be less than 25 years
There should be a positive family history
Sweating typically stops during sleep
How does hyperhidrosis affect health?
Regardless of which part is affected, excessive
sweating is a nuisance to those who suffer from it. Of
these, palmar sweating (sweaty palms) is the most
incapacitating. Primary idiopathic palmar hyperhidrosis
has no serious threat to life. However, there are other
emotional and physical disabilities arising from its
nuisance. Patients are not only uncomfortable, but
often socially and professionally embarrassed by it e.g. while shaking hands,
writing, playing musical instruments, handling paper, painting, using electronics,
computers, mobile phones etc. The problem usually begins in childhood and
gradually progresses during the teens and adulthood.
The sweating is usually precipitated by some emotional or mental stimulus e.g.
writing an exam, giving an interview, shaking hands with a social or business
acquaintance etc. It is a lot more when the person is outdoors in the sun or in a
warm place, but can be surprising nasty even within the confines of an airconditioned room. Excessive sweating from the palms and the soles are
predominantly due to emotional stimuli (emotional sweating) and are seldom or
never noticed during sleep. Excessive sweating from the rest of the body occurs
due to thermal stimuli (thermal sweating) and can occur anytime. The armpits
exhibits thermal and emotional sweating.
What are treatment options for sweaty palms?
Hyperhidrosis (excessive sweating) can be controlled to some degree with
commercial antiperspirants. However, stronger treatment is often needed,
especially for the palms of the hands, soles of the feet, armpits, or genital area.
Several solutions, gels, films, ointments or medications have been tried for this
condition. These often fail to give long lasting relief and surgery is a useful
alternative in these patients.
Topical Antiperspirants: Aluminum chloride may be effective when applied on
dry palms before sleep and washed off six to eight hours later. Gloves should be
worn for maximum benefit. It often causes chapping and cracking of the skin.
Some patients also experience skin irritation and burning. The palms often end
up feeling more oily or sticky and patients eventually stop using it. Certain
anticholinergic solutions (e.g. glycopyrrolate) have been known to benefit
excessive sweating from the face, but not from the palms. Topical antiperspirants
are usually not effective for severe sweating and dripping of the hands as it gets
washed off with the flow.
Oral Medicines: Anticholinergic drugs (that block the nerve sites) or
psychotropic drugs (that effect mental function) have also proven effective
against excessive sweating. These have to be taken long term and most patients
find them intolerable due to systemic side effects. These are not advocated for
localized or focal sweating.
Iontophoresis: This involves applying low-intensity electrical currents to the
hands or feet when they are immersed in an electrolyte solution. It requires
steady use and is needs to be done at least 3-5 times per week. This may reduce
or temporarily stop the sweating, but is time consuming and often painful.
Adverse effects include irritation, dryness and peeling of skin, vesicles, redness,
burning and stinging sensation, most of which resolves on stopping therapy.
Botox ®: This is a derivative of the deadly botulinum toxin, and is injected into
the affected area. The effect lasts only a few months, requires repeated periodic
injections and is expensive. This has been approved by the FDA for sweaty
armpits but NOT for sweaty palms and feet.
Surgery: Minimally Access Surgery has revolutionized the treatment of sweaty
palms. Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive
procedure that allows key-hole access to the sympathetic chain that lies deep
within the thorax (chest). The sympathetic chain is selectively blocked where it
sends out nerve branches to the sweat glands in the palm. Special instruments
are inserted into the chest through tiny holes with negligible scarring as
compared to conventional opening of the chest. It has excellent results (more
than 90%) which are usually permanent.
Others: Acupuncture, biofeedback, anti-anxiety medicines and various herbal
remedies have been tried with limited or no success.
SURGERY FOR SWEATY PALMS:
ENDOSCOPIC THORACIC SYMPATHECTOMY (ETS)
The sympathetic chain is a bundle of nerve
fibres that runs from the base of the skull up
to the tail bone. In the chest, it runs in the
back, along the ribs. The 2nd sympathetic
ganglion (T2) supplies the face (and palms
to some extent) and is usually blocked as a
treatment for facial hyperhidrosis or
blushing. The 3rd and 4th sympathetic ganglia
(T3, T4) are mainly responsible for palmar
sweating, though the Stellate ganglion (C7T1) innervates in 10% of the population. T5 (and T4 to some extent) is concerned
with sweating in the axilla (armpit).
Open surgical methods have been described for sweaty palms since the 1940’s.
These involved opening up of the chest wall to get
access to the sympathetic chain of nerve fibres.
There were difficulties in access and technique.
Large incisions meant more pain, discomfort and
healing time. Patients took long to recover and
resume normal activity. These procedures were
more
morbid
with
potentially
hazardous
complications.
The procedure is performed under general anesthesia. Single lung ventilation
allows one lung to be collapsed at a time to give good access to the sympathetic
chain. A small skin puncture is made and a 3-5mm cannula is introduced in the
chest. A video telescope is put into this
cannula to visualize the interior of the
chest. A second cannula is also
inserted to allow another instrument into
the chest. The sympathetic chain is
identified and ablated (cut or clipped) at
the desired levels. If symptoms are
bilateral, the same procedure is
performed on the opposite side.
Surgery offers immediate relief with the patient waking up from anesthesia with
dry hands. The effect is usually permanent. There is a good overlap of functions
of the sympathetic chain, so there are no know long-term side effects of the
sympathectomy. Most patients are discharged the following day. The procedure
is usually well accepted with good patient satisfaction and improved quality of
life.
What are the benefits of ETS?
ETS offers the following benefits:
• Small Scars
• Better cosmesis
• Reduced post-op pain
• Shorter hospitalization
• Earlier recovery and return to normal activity and work
• Reduced morbidity and mortality
• Immediate and usually permanent results
• Often, patients will also show an improvement in sweating from the feet
and armpits.
What are the postoperative complications of ETS?
No operation is without risk and can include anesthetic complications, bleeding,
infection and damage to surrounding organs.
Complications specific to ETS are rare, but include:
• Compensatory sweating: Once the palms (and soles) are dry, the body will
need to sweat from other areas to lose the excess heat and maintain the
normal body temperature. Most patients experience compensatory
sweating from other parts of the body like the trunk, face, lower limbs etc.
This is usually mild and less disturbing than the primary problem. This can
sometimes manifest as severe sweating from some part of the body (e.g.
back, hips etc) that may make the patient regret the procedure. It is
difficult to predict this outcome preoperatively and all patients must be
aware of this before embarking on ETS.
• Residual Symptoms: ETS will give excellent results in over 90% cases. In
the remaining, symptoms may partially or fully persist for unexplained
reasons. These include anatomical variations, aberrant nerve pathways
etc.
• Recurrence: occurs in 1-2% patients. This may be mild, usually in
situations like heavy physical activity, hot weather or other stressful
situations. A redo surgery is seldom required if symptoms are severe.
• Heart rate changes: Reduction in heart rate may occur in a few cases, but
has no physiologic significance and no long term effect on the
cardiovascular function.
• Pneumothorax: Sometimes air remains inside the chest after surgery. This
is usually insignificant and gradually gets absorbed. Rarely, a small
drainage tube may be required to be placed in the chest to let the air out.
• Gustatory sweating: Patients experience increased sweating while eating
or smelling certain foods. This is extremely rare.
• Horner’s syndrome: This is also known as ‘droopy eye syndrome’ and
occurs due to damage to the C7 ganglion if the sympathetic chain is
attempted to be cut high at the level of the Stellate ganglion (C7-T1). It is
very rare, as it is common practice to spare T1.
Conclusion:
Endoscopic thoracic sympathectomy (ETS) is an effective treatment modality for
primary palmar hyperhidrosis as compared to all other treatment options and is
considered the gold standard of treatment for the same. It is routinely performed
in as a ‘short-stay’ procedure with 24 hours hospitalization.
How do I get help for sweaty palms?
Dr Avinash Katara is an expert in key-hole surgery for sweaty palms. He has
research and clinical experience on sweaty palms and has several publications
on the subject. (with link on surgeon’s profile)
Articles in press:
• “Sweaty Palms”, Times Wellness (section of The Times Of India) – 10th
August 2008, Page 9 (with link)
• “Surgery to dry sweaty palms”, The Mumbai Age (section of The Asian
Age), 25th May 2008, Page 22 (with link)
• “30 minute surgery could cure sweaty palms”, The Times of India – 19th
December 2009, page 1&12 (with link)
• “Minor maladies, major troubles”, Health & Nutrition - June 2010, Page 3637 (with link)
• An icky, sticky situation, The Deccan Chronicle: 28th July 2010.
http://www.deccanchronicle.com/health/icky-sticky-situation-237
Articles in peer reviewed journals:
•
Katara AN, Cheah WK, So JBY, Domino J,Ning C, Lomanto D. T2 versus
T2-3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a
randomized control trial. Surg Endosc. 2007 Oct;21(10):1768-71 (with link)
Presentation in International conferences:
•
T2 versus T2-3 ablation in thoracoscopic sympathectomy for palmar
hyperhidrosis. Katara AN, Cheah WK, So JBY, Lomanto D. ELSA 2005,
7th Asia-Pacific Congress of Endoscopic Surgery (Hong Kong, August
2005).
•
Thoracoscopic T2 versus T2-3 sympathectomy for Palmar hyperhidrosis.
Katara AN, Domino JP, Iyer SG, Cheah WK, So JBY, Lomanto D. CSM05,
Combined Scientific Meeting-shaping a new era in healthcare (Singapore,
November 2005).
•
T2 versus T2,3 ablation in thoracoscopic sympathectomy for
hyperhidrosis. Katara AN, CheahWK, So JBY, Lomanto D. SAGES 2006
PostGraduate course and Scientific Session organised by the Society of
American Gastrointestinal and Endoscopic Surgeons (Dallas, April 2006).
Presentation in National conferences:
•
Promising results of bilateral endoscopic thoracic sympathectomy (ETS) in
patients with sweaty palms. Gaurav Mittal, Avinash Katara, Deepraj
Bhandarkar, Tehemton E. Udwadia. ASICON 2010, 70th Annual
Conference of the Association of Surgeons of India (New Delhi,
December 2010).
•
Overnight-stay bilateral thoracosopic sympathectomy in patients with
palmar hyperhidrosis. Avinash Katara, Gaurav Mittal, Deepraj Bhandarkar,
Tehemton E. Udwadia. MASICON 2011, 33rd Annual Conference of
Maharashtra Chapter of ASI (Mumbai, February 2011).
For more details contact:
Dr. AVINASH N. KATARA
MS, DNB, MNAMS, MRCSEd, Fellow-MIS(Singapore).
DEPARTMENT OF MINIMAL ACCESS SURGERY
PD Hinduja National Hospital & Medical Research Centre,
V.S. Marg, Mahim, Mumbai - 400 016, India.
Phone: +91 22 24452222, 24451515 (ext. no. 8267)
Direct: +91 22 24447267
Secretary: +91 22 24447277, 24447274
E-mail: [email protected]
FAQ - Common questions asked by patients are: