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 chest procedure.

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.

Conservative Treatment

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 dryness.

Surgery

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.

Retrodermal Curettage

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.

Advantages

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 methods.

Botox

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.

Lotions

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.

Oral medication

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.

Electronic Devices

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 Herbal Medicines

All of the above methods have been tried by some patients. No success has been so far reported.