Primary Hyperhidrosis is a chronic idiopathic disorder of excessive sweating
that mainly affects the axillas, the palms, the soles of the feet, and the face.
Focal hyperhidrosis causes appreciable social problems in both private and professional
life. Profuse sweating can result in skin maceration and secondary microbial
infections. Current treatments for axillary hyperhidrosis are often ineffective,
short acting, or not well tolerated.
Botulinum Toxin type A
has been used successfully in a range of medical disorders
including strabismus, blepharospasm, focal dystonias, and
spasticity associated with juvenile cerebral palsy and adult
stroke. In hyperhidrosis, botulinum toxin type A acts by blocking
the release of acetylcholine from overactive cholinergic nerve
fibres. These innervate eccrine sweat glands, so excessive
sweating is reduced. Several small, predominantly open label
studies and one placebo controlled study have shown that botulinum
toxin type A is safe and relieves symptoms of hyperhidrosis
for 3 to 14 months.
Axillary Hyperhidrosis, or Armpit
Sweating, involves extreme dripping sweat in the armpits
with constant odor that is usually resistant to all deodorants.
While the presence of axillary (armpit) sweat and Axillary
Bromhidrosis (odor) is normal in all people past puberty,
sufferers often experience excessive sweat dripping down the
arms and chest, preventing them from wearing certain fabrics
or colors. This also causes staining and damaging of clothing.
Caused by the over stimulation of the sympathetic nervous
system sweat glands, the condition may be aggravated by anxiety,
but it can occur without it. Axillary Sweating may be present
alone or in conjunction with any or all other types of Hyperhidrosis.
Dr. Jon M. Grazer, MD, MPH offers a surgical alternative
to excessive armpit sweating. The surgery, known as Retrodermal
Curettage. is a "new-old" approach to the problem
using an advanced treatment with a success rate of over 90%!
Dr. Grazer's procedure is performed on
an outpatient basis under twilight anesthesia. Following recovery
the patient is then discharged and has a post-operative visit
the day following the procedure. There is a light dressing that allows for normal mobility.
This surgery is a Non ETS surgery and
should not be confused with the Endoscopic Thoracic Sympathectomy
(ETS) approach which does not have the same results. ETS may
be the preferred procedure if you suffer from more than just
excessive armpit sweating. Its important to note the difference
between the two procedures. Dr. Grazer's Retrodermal Curettage
is the procedure of choice for those suffering from only excessive
armpit sweating and no other forms of excessive sweating,
or those patients that do not want to undergo a more invasive
The ETS procedure is best suited for those suffering from sweaty hands. However,
various reports indicate that for people who suffer from combined sweaty hands
and sweaty armpits, 40% to 80% will improve through the ETS procedure.
In people with significant axillary sweat or odor problems, deodorants and antiperspirants
often fail to control the sweat or odor. Anticholinergic medication, such as
Robinul, offer temporary relief and may cause total body dryness and drowsiness. Drysol
also dries the skin and requires lengthy treatment, causing a temporary result.
Botox can be injected into the affected area, but treatment requires multiple
injections that can be painful and need to be repeated every few months. Oral
medication such as Robinol offer temporary relief however it may create body
For many years, the surgical treatment of choice was excision of the axillary
skin, with or without removing subcutaneous tissue. But this procedure left
large scars, was subject to prolonged wound-healing, required an uncomfortable
compressive dressing, and limited motion of the shoulders and arms for an extended
period of time. It also caused total hair loss of the underarm area.
We now have a "new-old" surgical method for the treatment of axillary
sweat and odor. It is similar to a liposuction technique, in that way it is
done using similar equipment and instruments used in liposuction surgery with
sub dermal curettage (scraping of the tissue under the skin). One or two small
incisions, 0.5 to 1cm long (less than 1/4 of an inch), are made in the side
of the chest wall under the armpit area. Retrodermal curettage is then performed
in a criss-cross pattern to remove tissue at the affected area (The surgery
is performed under twilight anesthesia). Prior to curettage, the area is infiltrated
with a solution containing saline and local anesthetics (Lidocaine). Both
sides can be done at the same time. The purpose of this technique is to assist
curating and to reduce post operative pain and bleeding.
The procedure is performed on an outpatient
basis under twilight anesthesia. Following recovery the patient
is discharged and has a post-operative visit the day
following the procedure. There are limited restrictions in
daily activities, but exercise should be avoided for 3-4 weeks.
Post-operatively the patient is advised not to engage in excessive
physical activities due to limitations needed for healing.
Healing is relatively uneventful.
Possible complications include:
- occasional skin loss, which eventually heals
with a small axillary scar
- fibrotic bands under the skin that disappear
in a few weeks to a few months
- discoloration and hardening of the skin which
disappears within a few weeks or months
If fibrotic bands or hardening occur, massage and ultrasound will help in facilitating
the healing. Other problems which occur less often include: fluid collection, hematoma (a
collection of blood under the skin), and infection.
The Retrodermal Curettage procedure has
a number of advantages over other techniques. The hair distribution
pattern remains normal and the scars are tiny. Unlike endoscopic
thoracic sympathectomy (cutting or clamping of the sympathetic
nerves to prevent sweating in the extremities), it does not
lead to compensatory sweating in other parts of the body.
The surgery has a 95% success rate. Patients report fewer
problems with the surgery or healing and most are highly satisfied
with the outcome.
At the present time, clamping is the procedure of choice and the one
recommended by Dr. Grazer. The primary reason for using the clamping procedure
is that it leaves the possibility for easier reversal, easier in the sense of
technically and physiologically. In the cutting method, when a patient is unhappy
with the results of the procedure a reversal may be done by performing a nerve
graft operation. This procedure is very difficult to perform. In the clamping
method, reversal is much easier because it simply requires removal of the clips
and by doing so gives the nerve segment a possibility for regeneration. It has
been shown that some patients having the clamps removed showed lessening of
the compensatory sweating to total disappearance of the compensatory sweating.
Most patients are able to walk out of the medical center within 2 hours
after surgery. Regular physical activity and returning to work are possible
in one week or less. Scarring is minimal as the incisions are small and well
hidden in the folds of skin of the armpit.
Alternatives to surgery:
For decades, attempts at countering excessive sweating through alternative
methods have been made. Conservative solutions, such as Botox, lotions, oral
medications, electronic devices, acupuncture, anti-anxiety medications, beta
blockers, biofeedback, and herbal medicines have had little or no effect on
the problem. The only highly effective and permanent solution has been surgery.
That said, surgery should not be resorted to without attempting some of these
alternative methods. In fact, many insurance companies demand that alternatives
be tried before surgery is concluded upon. Most patients who undergo surgery have already attempted to use the conservative
Botod is sometimes used for the treatment
of axillary sweating, but here, as in other forms, the results
are only temporary. When one attempts to treat sweaty hands
with Botox, the procedure is extremely painful, to the degree
that some patients require twilight anesthesia. Finally, it
is an expensive procedure, and as it is only temporary, must
be conducted on a regular basis to be continuously effective.
The most commonly used lotion is an aluminum hydrochloride known as Drysol (manufactured
by Person & Covey, Inc.- Glendale, CA). In most states, Drysol is available
through prescription and in some, it can be purchased over the counter. The
aim of the lotion is to cause dryness of the hands. Unfortunately, most patients
do not feel any relief due to the fact that the application of any lotion causes
more wetness. Long term usage can cause cracking of the skin but without actually
decreasing sweating. Maxum is another product on the market with a somewhat
higher pH level, causing less irritation. Maxim can be purchased online. All
drawbacks taken under consideration, lotions are the first step in attempting
alternative methods to surgery.
For years, physicians have treated hyperhidrosis with a group of medications
that were used to treat peptic ulcer problems. Those medications work by inhibiting
a certain neurotransmitter (a chemical substance) that interferes with some
receptors that have a role in the production of sweat. In these medications,
such as Robinul, Ditropan and Propantheline, success is very limited and some
patients discontinue use due to side effects such as dry mouth and blurry vision.
Drionic (manufactured by General Medical Co. – Los Angeles, CA) is an
electric machine that uses iontophoresis as a means of slowing sweat production.
Hands are placed in a tub like container full of water and weak electric currents
run through the water. It requires steady use – at least three to five
times a week - and can be purchased online. Success is reported to be very limited.
Acupuncture, Biofeedback, Anti-anxiety medications, Beta blockers and
All of the above methods have been tried by some patients. No success has been
so far reported.