Causes of hyperhidrosis
Hyperhidrosis, or to sweat excessive, is a disorder that can cause the social isolation or the professional incapacity. It can be generalized or can be located, and although frequently idiopathic can be a demonstration of several illnesses center for hyperhidrosis important. The drugs, the surgical procedures, and electric devices that all can be employees by the doctor you arm as therapeutic to treat hyperhidrosis.
The primary function of the glands sudar causes of hyperhidrosis íparas of eccrine is to participate in the conservation of corporal temperature to heat the exposition or the exercise. Hyperhidrosis can be defined sweating as beyond what is necessary to maintain the thermal regulation. It can be primary (idiopathic, essential) or secondary to several illnesses and drugs prescribed. It can be located, regionalized, or generalized (1). In spite of the type or the cause of the hyperhidrosis, frequently shames incapacitates professionally and socially. The sweat of the excess in the hands is able role of land and the art works and does it virtually impossible to play many musical instruments. The careers in fields that require the contact with role, the metal, or the electric components come they be unrealizable. Axillary and hyperhidrosis of the plant they can have as a result the spots and the damage to the clothes and shoes. It generalized or hyperhidrosis of regionalized can leave individuals affected with the center for hyperhidrosis clothes wet that can have that to be changed various times each day.
Physiologically, sweating is a function of the nice nervous system. A center of the control of the sweat located in the area of preoptic and previous hypothalamus contains the neurons that are sensitive to changes in the temperature and also cerebral cortical internal events. The glands sudaríparas are innervated by nice fibers of postganglionic but, as opposed to innervation nice ordinary, the chemical mediator is acetylcholine. Sweating in answer to thermal stimuli he is generally acceptable and rarely a cause for the complaint. Sweating emotionally-induced tends to be located to the palms, the soles, and at times the front. Sweating of Axillary can be the result of both thermal and emotional stimuli.
The causes for the hyperhidrosis generalized (Postpones 1) includes several feverish illnesses, neoplastic and neurological illnesses, the metabolic disorders, and the drugs. The causes and the conditions associated with hyperhidrosis located (Postpones 2) includes hyperhidrosis primary causes of hyperhidrosis or focal, hyperhidrosis circumscribed unilateral, hyperhidrosis associated with neoplasms of intrathoracic, with hyperhidrosis olfactory, with hyperhidrosis taste, with the injuries of the spinal cord, and with syndrome of Frey. Although hyperhidrosis primary or focal be the most common cause of hyperhidrosis of palmoplantar, can occur also in some patients with the illness of Raynaud, rheumatoid arthritis, erythromelalgia, nail kneecap syndrome, palmaris of keratosis et plantaris with clinodactyly, with fistula of atrioventricular, and with the cold injury. Provided that possible the cause for the hyperhidrosis should be identifying and if is possible treaty.
Hyperhidrosis primary or focal is a disorder in which there is to sweat of excess of the hands, of the feet, of the face, and of axillae. A recent national inspection reckoned that 1,4% of the population of United States . (4,0 million individuals) suffers from the hyperhidrosis of axillary (2). A third of these victims (1,3 million individuals) describes its to sweat as barely tolerable or intolerable, and that frequently or always intervenes with its everyday life. Hyperhidrosis primary can be inherited and by contrast to the hyperhidrosis generalized has generally its time of the beginning in the childhood or the adolescence (3). Hyperhidrosis of palm grove begins generally in the hyperhidrosis of childhood and axillary in the adolescence. Typically, hyperhidrosis focal does not occur upon sleeping. Hyperhidrosis primary is aggravated for the heat and emotional stimuli; nevertheless, is important to note that although the emotional stimuli be necessary for the hyperhidrosis primary to center for hyperhidrosis occur in individuals affected, is not a psychological illness but a physiological disorder. Seems that in patients with hyperhidrosis primary, the centers of the sweat of hypothalamic are more sensitive to emotional stimuli of the cerebral origin that those in ordinary people. The occasional beginning of hyperhidrosis primary in the neonatal period is the evidence that this is a lot more than an emotional disorder!
Various surgical and medical remedies are available for the processing of hyperhidrosis (Postpones 3).
The chloride of the aluminum and to tan agents are at times troops in the control of hyperhidrosis located (4). The chloride of the aluminum can diminish to sweat for blocking mechanically pores of gland sudarípara of eccrine, although this mechanism have been disputed. The atrophy of the cells secretory views in glands sudaríparas of eccrine exposed to the chloride of the aluminum can justify the to sweat reduced that the majority of the people they enjoy with the use of the products that contain chloride of aluminum. For the majority of the people with hyperhidrosis of axillary, the products without prescription are sufficient. To sweat more severe, Drysol [R] (20% of hexahydrate of chloride of aluminum was dissolved in the alcohol anhidro of ethyl; Person & the Clutch, INC., Glendale , CA ) is frequently useful. The skin should be dried before the application, since if the humidity is present then irritating hydrochloric acid can form. Washing a short time before of the application should be avoided. The optimum way to utilize the product seems to be to apply it in hour to be gone to bed to be take advantage of the relative inactivity of glands sudaríparas at night and to wash the product first thing in the morning. The secondary irritation can be alleviated with the use of creams of hydrocortisone. The product should causes of hyperhidrosis be utilized nocha until an effect occur and then the interval among applications can be extended. Although occlusion with plastic wrap can be tried if directs the application is not cash, this method is not only inopportune but often has as a result irritation enlarged.
Glutaraldehyde, tánico acid, and the formaldehyde can be useful to treat palm grove and hyperhidrosis of the plant, but its tendency to stain the skin (and the sensitizing the potential of the solution of formaldehyde) limits its utility (5).
The Processing sistémicos For those patients whose hyperhidrosis is related to specific events of anxiety-producing such as a speaking engagement, educates etc. of dance, the use of a drug just as Valium [R] (diazepam) can have an improving the affection. If hyperhidrosis is a part of a social disorder of the anxiety, Prozac [R] (flouxatine) can be a very useful therapeutic agent along with the appropriate psychiatric care. Anticholinergics sistémico can be useful, but unfortunately the dose requirieron to manage to sweat reduced has as a result also the effects of the side inclusive xerostomia, mydriasis, cycloplegia, and dysfunction of intestines and vesícula. The majority of the patients with hyperhidrosis located or generalized they cannot tolerate them for long. Nevertheless, the anticholinergic Ditropan [R] (oxybutynin) has been found to be useful in the relatively rare syndrome of hyperhidrosis episodic with hypothermia (6). A second one anticholinergic, Cogentin [R] (benztropine) was utilized successfully to treat hyperhidrosis in a patient with sweating venlafaxine-induced of excess (7). Effexor [R] (venlafaxine) is an antidepressant that inhibits the reuptake of serotonin and norepinephrine. Sweating is said to occur in the meantime as 12% of all patients exposed to the venlafaxine and another selective inhibiting serotonin of reuptake (SSRIs). The not-steroidal indomethacin anti-inflammatory of agent in a dose of 25 mg T. I. D, was prescribed for a patient with arthritis that had coincidentally center for hyperhidrosis idiopathic of all the life generalized hyperhidrosis (8). Enough unexpectedly, she enjoyed a resolution of her hyperhidrosis of all the life. Although the mechanism for this beneficial effect be not clearly, the fact that prostaglandin AND is found in quantities enlarged in the sweat of some patients with hyperhidrosis can give explanations (9). The entrance of calcium of the extracellular to the space intracelular is necessary for the secreción active of the sweat by glands sudaríparas of eccrine. This probable one justified the improvement in the palm grove and hyperhidrosis of the plant observed when a blocker of the channel of calcium, diltiazem, was utilized to treat a family with palm grove and hyperhidrosis of the plant (10). Antidepressants of Tricyclic can cause to sweat of excess, and but one would expect that the action of anticholinergic of tricyclics should to block to sweat, it does not induce. Catapres [R] (clonidine), a stimulant centrally assets of autoreceptor [alpha.sub.2]-adrenergic, has been found to be useful in the processing of hyperhidrosis due to tricyclics as well as menopausen (11). Darvon [R] (hydrochlorate of propoxyphene), a narcotic and ganglionic weak that block agent, they can have an improving the effect in the hyperhidrosis in patients with dysreflexia autonomous (12). Dysreflexia autonomous is a syndrome of nice hypercritical due to the distension of vesícula or internal view in some patients with wounds of spinal cord in or over the sixth level excessive sweat antiperspirants and medication (T6). The acetato of Fludrocortisone 0,3 mg can control daily to sweat in tetrapléjico in who low blood pressure of orthostatic precipitates a nice discharge (13). The reader is notified that many of these reports of the therapeutic efficacy are anecdotal, and all these agents sistémicos carry with them the risk of sideways effects.
Of all the types of hyperhidrosis, hyperhidrosis focal, that can imply the axillae, the palms, the sole and the face, they are the very common one. Two therapeutic interventions, an old one (causes of hyperhidrosis) and a relatively new one (toxin of toxin botulínica), they are especially valuable in the processing of hyperhidrosis primary or focal.
The return to Surpass
One of the simplest, surer one, and the majority of the profitable processing for the palm grove and/or hyperhidrosis of the plant they are that of iontophoresis, that is defined as the introduction of a substance ionized by intact skin by the application of a direct current. In 1936, Ichihashi utilized several solutions of atropina, of the histamine, and of the formaldehyde and showed that sweating of the palms could be reduced by iontophoresis (14). Its work was relatively unnoticed until 1952, when Bouman and Gruenwald Lentzer published center for hyperhidrosis a report showing clearly the efficacy of iontophoresis for the processing of palm grove and hyperhidrosis of the plant in 113 patients (15). They showed that the addition of a substance of ionizable to the water was not necessary to obtain a therapeutic effect. Levit showed a simple galvanic device that could be an employee to alleviate hyperhidrosis in 85% of patients affected (16,17).
Although the exact mechanism by which iontophoresis alleviate palm grove or hyperhidrosis of the plant they are not known that is considered due to covering of poral, since the effect is invested for tapestripping of cellophane of the skin that covered glands sudaríparas of eccrine euhidrotic yielded by iontophoresis (18,19). For those patients that fail to respond to the simple water iontophoresis current, the addition of an anticholinergic directly to the running water filled trays of processing they are frequently useful.
Although various devices be available for the administration of iontophoresis, this author prefers the Fischer MD1a the Galvanic unit, and the employed technique are described in Tables 4 and 5. The effects of the side of the iontophoresis are few. Occasionally the palms arrive at to be dried also and can arrive at to be cracked or with cracks. This can be alleviated with the use of moisturizers and/or a reduction in the frequency of processing. The erythema -- and less frequently vesiculation of the skin -- can continue the processing and can be tried if necessary with simple 1% of cream of hydrocortisone. Hyperhidrosis compensatory does not occur. Iontophoresis is difficult to administer to the axillae and seems to cause more irritation than when administered to the palms and soles; thus not as useful for the processing of hyperhidrosis of axillary.
Toxin of toxin botulínica
Justinus Kerner, a doctor and the German poet, they published the first complete description of the symptoms of the botulism between 1817 and 1822. The it proposed also the possible therapeutic use of toxin of toxin botulínica, that called "sausage poison". The monograph of Kerner (20) describes the following illness of I consume he cooked inadequately he smoked bloodsausages: The liquid of the tear disappears, the esophagus comes be a dead and motionless pipe: in all mucous cavities of the human mechanizes the secreción of the normal backups of mucus still, of the largest one, the stomach, toward the channel of the tear and the conduits excretorios of the lingual glands. Any saliva is secreted. Any drop of the humidity is felt in the mouth, any tear is secreted more [....] The Urination only can be carried out causes of hyperhidrosis stopping, and with difficulty. The extreme that drought of the palms, the soles, and the eyelids occur. Kerner passed to describe the additional effects in humans and animal: vomiting, the intestinal spasms, center for hyperhidrosis mydriasis, ptosis, dysphagia, and to the end, the respiratory failure. Its reputation as an expert in "sausage that poisons" gained it the "Sausage of nickname Kerner". Subsequently poison of sausage was called the botulism of the latin american word for the sausage, botulus. Years later, in 1895, the bacteria responsible for the botulism was identifying by small truck of Emil-Pierre Ermengem.
Today toxin of toxin botulínica is an useful therapeutic agent for the processing of several illnesses related to the dystonia muscular. This powerful toxin has tested to be a remedy extremely cash for the processing of previously recalcitrant conditions in the fields of the ophthalmology, of otorhinolaryngology, of the pediatrics, of the gastroenterology, and of the urology. The denervation cosmetic of muscles of the facial expression that utilizes toxin of toxin botulínica has given dermatologics and plastic surgeons a new weapon against wrinkles and lines expression-induced facial. The in recent years certain types of hyperhidrosis have been treaties successfully with toxin of toxin botulínica. The side carries out reported continuing the local injection of toxin of toxin botulínica has been few and is related generally to undesired weakness in adjacent muscles to the places of the processing.
The processing of Axillary Hyperhidrosis
The patients with the quality to damage of the life that hyperhidrosis of axillary should be offered the processing with or toxin of toxin botulínica or ablation surgical of the glands sudaríparas of axillary. Since toxin of toxin botulínica does not only inhibit the liberation of acetylcholine in junctions of neuromuscular but also in postganglionic nice fibers to glands sudaríparas, they have been found to be useful to treat hyperhidrosis of axillary (21-27). In the processing of hyperhidrosis of axillary as little as 50 units injected and intradermally distributed to each axilla can produce euhidrosis that hard as long as 6 months. With larger answers of dose has been as long as 15 months. Many clinical carry out a test of the iodine of the starch before the processing to document the extension of the hyperhidrosis and for identify any so called "places of danger," that is areas that produce the largest quantities of the sweat. This author utilizes a simple facial weaving and a gentian violet scoreboard to identify such areas. The hyperhidrosis occurs generally in the area of hair-bearing of the axillae and so is in these areas that the toxin should be placed. The inconvenience is simple and minimum ice pack applied to the axillae before injection they are sufficient for the anesthesia.
The patients with hyperhidrosis of axillary that are unfeeling to the trite therapy do not they want toxin of toxin botulínica neither in whom is contraindicated neither wants simply that a more lasting remedy can be offered a variety of surgical techniques designed to the ablate the glands sudaríparas of axillary. The areas of the largest production of the sweat can be identifying drapeando a piece of facial role of weaving on the axilla or a test of the iodine of the starch. At times this area is quite small and a simple eradication with the closing is sufficient to the remedy the problem (28). The patients with moderate to the center for hyperhidrosis severe can require a more extensive procedure with undermining and triangulation of all glands sudaríparas exposed (29). To obtain the good closing and to avoid the limitation of the movement due to contracture causes of hyperhidrosis, Z-plasty and eradications and repairs bats-formed can be employees (30). The alternative processing for the hyperhidrosis of axillary include subcutaneous liposuction and subcutaneous scraping (31,32).
The processing of Hyperhidrosis Obvious OF THE PLANT
The patients with palm grove or hyperhidrosis of the plant should be given a trial of an antitranspirant of the prescription forces just as Drysol [R] before toxin of toxin botulínica or iontophoresis treatments(32). The injections of the toxin botulínica are very cash for the processing of hyperhidrosis of obvious (33-35). The dose utilized they are generally more high than those utilized for the hyperhidrosis of axillary, traveling through from 100 to 200 units of Botox [R] by hand. Euhidrosis such following processing can last while a year. Although effective, the clinical utility of this processing be limited by the need for repetitive relatively painful injections, the cost of the toxin of toxin botulínica, and of the reports of the weakness of the small muscles of the hands (33). Anesthesia is obligatory for the toxin toxin administration botulínica at hand or feet. Although trite anesthesia in the shape of Elamax [R] low occlusion by an hour followed by compresses of ice seem satisfactory for some, the majority of the doctors they have found the need for an or a block of you Walk or a block of the median, of ulnar, and of radial nerves (36). Walk you block them, once learned, they are not only sure and effective but they carry also with himself the advantage on blocks of nerve of affect not the function of the motor. As a consequence, the patients can utilize still the hands immediately after the processing.
Iontophoresis remains still an useful therapy since toxin toxin injections botulínica for the processing of palm grove and hyperhidrosis of the plant they are not convenient for all patients (32). Specifically, the musicians, the surgeons, and the other that depend on fine the motor dexterity in hands cannot be able to accept the risks of the force diminished of the thumbs that can accompany toxin toxin injections botulínica. Young children cannot accept the inconvenience implied in neither regional blocks of nerve neither a block of you Walk for the anesthesia for injections of toxin botulínica in the hands. Finally, iontophoresis is much less costly that the processing of toxin botulínica causes of hyperhidrosis for the palm grove and hyperhidrosis of the plant, having present that from 100 to 200 toxin toxin units botulínica is utilized for hand and to go fees of the anesthetic/administration would be implied.
The processing of Craniofacial Hyperhidrosis
Hyperhidrosis of Craniofacial can respond to antitranspirants trite such as Drysol [R] or glycopyrrolate trite. Glycopyrrolate center for hyperhidrosis trite has been found to be useful to treat hyperhidrosis taste of craniofacial in diabetic (37). Toxin of toxin botulínica is very cash for the hyperhidrosis of craniofacial and is considered the processing of the election for patients with syndrome of Frey. Syndrome of Frey is characterized for hyperhidrosis taste unilateral that occurs in the meantime as 50% of patients that has a parotidectomy (38). The most probable explanation is reaparición of parasympathetic fibers of nerve that have lost the "organ of the objective". When toxin of toxin botulínica is utilized to treat hyperhidrosis of craniofacial that the technique differs that to treat the facial musculature in which the injections are more superficial (that is to say, intradermal) and evenly distributed on the area of hyperhidrotic. The area can be identifying by or the technique of the iodine of the starch or a facial weaving had against the skin. The toxin of the toxin botulínica causes of hyperhidrosis, 50 to 100 units of Botox [r], they should be administered at least one and media centimeters over the bridge of supraorbital to avoid a forward drop.
Sympathectomy or upper excessive sweat antiperspirants and medication (T2) ganglionectomy often is offered patients with hyperhidrosis severe of palm grove. Sympathectomy lumbar is not an employee generally for the hyperhidrosis of the plant on account of the risk of sexual dysfunction. Although the efficacy of this procedure in the processing of hyperhidrosis of palm grove be not doubtful, with rates of success of 9299%, the potential complications ate significant. Among the probable complications related (24% to 100% depending on the study) they are hyperhidrosis compensatory (to sweat enlarged in some another area of the body), to sweat taste (sweating, generally of the face, related upon eating of food), permanent syndrome of Bargains, the infection of injury, hemothorax, intercostal neuralgia, and the reaparición of hyperhidrosis (39-48). The arrival of sympathectomy endoscopic has reduced the incident of many complications.
Hyperhidrosis compensatory is the most common complication and the main motive for the patient discontent with the procedure. Sympathectomy compensatory of following of hyperhidrosis can be a lot more life-interrupting that hyperhidrosis of palm grove in which sorrowful individuals can have that to change the clothes sweat-soaked two or three times for day. In a recent systematic revision of the literature of sympathectomy for the processing of hyperhidrosis that the question was asked, "we Are paying a lot of money for the sympathectomy surgical"? 135 articles are revised, reporting in 22.458 patients and 42.061 procedures. 84,3% of the patients reported had the surgery for the hyperhidrosis. Hyperhidrosis compensatory occurred in 52,3% of the patients, to sweat taste in 32,3%, ghost that sweats in 38,6%, and syndrome of Horner in 2,4%. On the whole, the neuropathic complications occurred in 11,9% but they were less common in patients that had the procedure for the hyperhidrosis (48).
They dwell (45) indicates the enough succinctly: "The complications related to the surgical focus, just as syndrome of Homero, the brachial injuries of plexus, pneumothorax, and the painful scars can occur, upon continuing sympathectomy hyperhidrosis compensatory is usual and hyperhidrosis can occur again".
The patient that complains of hyperhidrosis presents the doctor with a therapeutic and diagnostic challenge. The patients that present with hyperhidrosis he generalized they are in the general adults whose to sweat occurs during the to awake and sleepy hours. Such patients require a search for a cause that can be at times as simple as a drug that take for some medical disorder. Occasionally an illness sistémica can justify the beginning of hyperhidrosis and a complete exam and to appropriate to test can be necessary to identify the cause. The majority of the patients with the primary or focal present of hyperhidrosis in the childhood or the adolescence and has a problem located to its axillae, to the hands, and/or to the feet. They have a physiological disorder, not a psychiatric one neither the illness of endocrinologic. Various remedies center for hyperhidrosis, trite, surgical and electric they are available for the processing of hyperhidrosis. The patients with hyperhidrosis of the palm or the soles that fail to respond causes of hyperhidrosis trite agents deserves a trial of the conservative therapy, of toxin of toxin botulínica, or of iontophoresis the before aggressive surgical techniques that carry with them the risk of uncomfortable effects of all the sideways life is offered.
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