Idiopathic localized unilateral hyperhidrosis: case report of successful treatment with botulinum toxin type A and review of the literature

BACKGROUND

Localized unilateral hyperhidrosis (LUH) is a rare disorder of unknown origin. We describe a patient with LUH on the forearm, where a fracture was identified as a past injury.

OBSERVATIONS

We treated the patient with botulinum toxin type A injections, and he was complaint free during the 6 months after treatment. In addition, the initially strong positive results of the iodine starch test (Minor sweat test) were negative in the affected region after treatment.

CONCLUSIONS

This relatively new therapeutic modality already established for axillary, palmar, and plantar hyperhidrosis seems to be efficient in LUH. As the former therapeutic approaches are rather disappointing, and as botulinum toxin type A locally applied shows limited adverse effects, we think a trial of botulinum toxin type A is justified in cases of LUH, even as a first-line treatment. In addition, the literature considering localization and causes of LUH is reviewed.

Ultrastructure of the hyperhidrotic eccrine sweat gland

BACKGROUND

Hyperhidrosis is the secretion of inappropriately large amounts of sweat by eccrine glands; it can be very debilitating. Little is known of the causes of primary hyperhidrosis.

OBJECTIVES

To determine whether the glands exhibit any structural abnormality in primary hyperhidrosis.

METHODS

Skin biopsies were obtained from the axilla (n = 6) or neck (n = 2) of individuals aged 26-62 years with primary hyperhidrosis and from five age- and sex-matched normal individuals, with informed consent and ethical committee approval. Samples were prepared by standard methods for light and electron microscopic examination.

RESULTS

All characteristics observed in the hyperhidrotic specimens were consistent with the changes seen in normal glands following strong activation: degranulation of the granular (dark) cells, dilatation of the basolateral infoldings and the canaliculi of the non-granular (clear) cells, contraction of the myoepithelial cells and thickening of the basal lamina, and presence of cellular debris including lipid droplets in the gland lumen. Pathological changes were not observed.

CONCLUSIONS

The present finding of the absence of structural defects in the glands indicates that future studies should concentrate on the investigation of neurohumoral or secretory cell metabolic abnormalities.

A hypothalamic stroke producing recurrent hemihyperhidrosis

A 40-year-old man awoke with exuberant sustained sweating of the entire left side of the body, which became intermittent over the next few days. MRI indicated a single linear hyperintensity in the right posterior hypothalamus, diminishing on a repeat scan. He continues to have episodes of left unilateral sweating precipitated by exercise or minor infection.

The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration

Thoracoscopic T2-T3 sympathectomy is the treatment of choice for primary palmar hyperhidrosis (PPH); however, compensatory hyperhidrosis (CH) is a disturbing sequela of this operation, the mechanism of which is poorly understood. This study was conducted to evaluate the effect of heat stress on total body perspiration after thoracoscopic T2-T3 sympathectomy, and determine its correlation with CH. A total of 17 patients with PPH who underwent bilateral T2-T3 sympathectomy were subjected to heat stress induced by a 10-min sauna bath (ambient temperature 70 degrees C), 1 day before and 1 month after surgery. The naked body weight was recorded before and immediately following the sauna bath, and the patients were followed up to assess whether CH had developed and the degree of its severity. Postoperatively, the amount of perspiration increased in 13 patients and decreased in 1. The amount of perspiration induced by the sauna bath ranged from 60 to 480 g, with a mean value of 185.29 +/- 125.80 g, before the operation, and from 60 to 540 g, with a mean value of 265.88 +/- 154.05 g, after the operation (P = 0.0113). There was no correlation between the degree of alteration in total body perspiration and the development of CH. Performing thoracoscopic T2-T3 sympathectomy for PPH affects the total body sweating response to heat; however, the development of CH does not correlate with this alteration.

Spinal dysraphism presenting as acro-osteolysis: report of four cases

The acro-osteolyses are a heterogeneous group of disorders characterized by bone resorption. The disorder may occur as familial, idiopathic, or secondary to vascular, inflammatory, or neurologic conditions. Acro-osteolysis is rare in association with spinal dysraphism. It is even rarer for it to be the presenting symptom in spinal dysraphism. We report here four patients in whom the diagnosis of spinal dysraphism was established while investigating for the various causes of acro-osteolysis. All four patients presented with trophic changes and acro-osteolysis. Hyperhidrosis in the affected limb was seen in three patients. One patient had leg pain, the others had no sensory or motor deficits. Magnetic resonance imaging showed spinal dysraphism in all four patients.

Clinical evaluation of atopic hand-foot dermatitis

Clinical manifestations of atopic hand-foot (H-F) dermatitis have not been well studied. This study examined 108 atopic dermatitis (AD) patients with H-F dermatitis between May 1997 and July 1999 at our AD clinic to determine the clinical characteristics of atopic H-F dermatitis and to assess its etiologic associations. It usually began in childhood with an early onset of AD. Pruritus was the most frequent symptom, and erythema, scales, lichenification, hyperkeratosis, fissures, and keratolysis exfoliativa were also common signs. Both the hands and feet were involved in 47 (44.0%) patients, and either hand or foot involvement was observed in 15 (13.9%) and 46 (42.6%) patients, respectively. Palmar or plantar surfaces were more frequently involved than the dorsal aspects. The great toe was affected more often than the other toes. Two-thirds of patients presented with manifestations of the ichthyosis triad and sandpaper-like skin lesions on the elbow, knee, and lateral malleolus. Palmar or plantar hyperhidrosis was reported in 15% and 20%, respectively. The ichthyosis triad-associated group showed a significantly higher incidence of sandpaper-like (thickened, roughened) skin lesions, and these patients had lesions on the dorsal hands or heels and lateral malleolus more frequently than ichthyosis triad-absent patients. The hyperhidrosis-associated group showed an association with glassy lesions, localized to palmar or plantar areas. Atopic H-F dermatitis is associated with the nonallergic etiologies of AD and clinical subgroups can be identified on the basis of nonallergic backgrounds.

Basal forebrain malformation with hyperhidrosis and hypothermia: variant of Shapiro's syndrome

A 62-year-old woman presented with episodic sweating and shivering with reduced core temperature. Brain MRI demonstrated a basal forebrain malformation. Physiologic testing included EEG, SPECT, heat challenge, and autonomic testing. Glycopyrrolate aborted spells and raised core temperature. Hypothalamic dysregulation is likely the primary pathophysiology in the setting of other forebrain anomalies. These findings expand the structural abnormalities and treatment options within the temperature dysregulating conditions of Shapiro's syndrome and "diencephalic epilepsy."

Histopathological examination of chemo-sympathectomy in cats

In recent decades, there has been an increase in both the number of sympathectomy techniques, as well as the surgical findings of sympathetic anatomy. Currently the advanced technique of C-arm guided percutaneous thoracic chemo-sympathectomy is widely used for the treatment of palmar hyperhidrosis. However, a better understanding of chemical agents in sympathectomy is required. In this study, chemo-sympathectomy was performed in cats, using alcohol, glycerol and various concentrations of phenol, to determine the chronic neurotoxic effects of these chemical agents on the stellate ganglia. The stellate ganglia of 24 cats were exposed under endotracheal general anesthesia, then injected with about 0.02 ml of absolute alcohol, glycerol and phenol (10%, 25%, 50%, and 75% concentration) solutions, respectively. The stellate ganglia were taken for histological examination three weeks after the chemical injection. The results showed that the degenerative changes in the cytoplasm and nucleus of ganglionic cells and intercellular tissue were moderate and relatively moderate after the injection of alcohol and glycerol, respectively. Meanwhile, the stellate ganglia revealed mild, relatively moderate, serious and extremely serious degeneration after injection of 10%, 25%, 50%, and 75% phenol, respectively. In conclusion, we recommend a high concentration of phenol, in the least volume, as a chemical agent for clinical injection in the upper thoracic sympathetic ganglion.

Botulinum toxin type A therapy for palmar and digital hyperhidrosis

OBJECTIVE

We evaluated the efficacy of subepidermal injections of botulinum toxin type A on recalcitrant palmar and digital hyperhidrosis.

METHODS

Twenty patients with recalcitrant palmar and digital hyperhidrosis were treated with subepidermal injections of botulinum toxin. Nineteen patients completed the 12-month study. Injections were performed in 3 stages. The total dose of toxin for each hand, which included the palm, thenar eminence, and digits, was 165 units. Patients were followed up on a monthly basis.

RESULTS

Botulinum toxin significantly reduced sweat production in the treated areas. Anhidrosis lasted 9 months in 3 patients, 8 months in 3 patients, 7 months in 8 patients, 6 months in 3 patients, 5 months in 1 patient, and 4 months in 1 patient. Reduced sweating of the palm and digits continued in all patients for the 12-month evaluation period, with the greatest reduction of sweating in the nondominant hand. Mild weakness of the thumb occurred in 4 patients at a mean duration of 3 weeks, with the greatest duration being 6 weeks.

CONCLUSION

Botulinum toxin provides a safe and efficacious alternative in the treatment of recalcitrant palmar and digital hyperhidrosis.

Selective degeneration of sudomotor fibers in Ross syndrome and successful treatment of compensatory hyperhidrosis with botulinum toxin

We report a 5-year follow-up of a patient with Ross syndrome. A biopsy of the anhidrotic skin immunostained with protein gene product 9.5 visualized by confocal microscopy revealed selective loss of sudomotor fibers, whereas epidermal innervation remained intact, providing the first morphologic evidence of selective loss of sudomotor fibers in this syndrome. Among the different treatment strategies employed for the patient's disabling segmental hyperhidrosis, intracutaneous injection of botulinum toxin A was the most helpful.

Carbon dioxide laser treatment vs subcutaneous resection of axillary osmidrosis

BACKGROUND

Axillary osmidrosis is a distressing disorder characterized by unpleasant odor, profuse sweating, and occasional staining of clothes that may handicap those affected both socially and in the work place. Various types of surgical procedures have been developed for the treatment of axillary hyperhidrosis and osmidrosis.

OBJECTIVE

Our purpose is to seek a more effective surgical procedure than preexisting various subcutaneous resection techniques for axillary osmidrosis.

METHODS

After single transverse incision in the center of one axilla, undermining was performed from the incision edges to make a wide subcutaneous tunnel and then apocrine glands and subcutaneous fats were vaporized with a CO2 laser. Subcutaneous resection technique was performed on the opposite axilla in the same patient. A total of 20 patients have been evaluated for 4 months to 1 year, with an average of 8 months.

RESULTS

The results from commonly used surgical procedures can be improved upon by the use of the CO2 laser. The frequency of complications and the mean duration of suture removal were diminished on the laser-operated side.

CONCLUSIONS

CO2 laser vaporization in osmidrosis produces significant patient-benefit during the postoperative course. We believe that this laser-assisted combined surgical procedure can be a viable option for the treatment of axillary hyperhidrosis and osmidrosis.

Primary digital clubbing associated with palmoplantar keratoderma

The association of hereditary palmoplantar keratoderma and idiopathic clubbing of the digits in the same patient is uncommon. The differential diagnosis includes the Bureau-Barrière-Thomas syndrome, primary pachydermoperiostosis, Fischer's and Volavsek's syndromes, and palmoplantar keratoderma Vörner. A 30-year-old woman with palmoplantar keratoderma and clubbing of the fingers since the age of 13 years is presented.

Coexistence of subepidermal calcified nodule and keratosis punctata in a patient with hyperhidrosis

A 47-year-old female with hyperhidrosis developed multiple subepidermal calcified nodules and keratosis punctata on her palms. Although calcification was not detected on eccrine sweat glands around the calcified mass by histologic examination, it was supposed that the eccrine sweat glands may have played a role in inducing these two lesions in our case.

Apert's syndrome (acrocephalosyndactyly) in a patient with hyperhidrosis

Apert's syndrome, also known as acrocephalosyndactyly, is a rare type of premature craniofacial synostosis characterized by the clinical triad of cranial and facial malformations along with syndactyly of the hands and feet. Acne vulgaris involving atypical sites such as the upper extremities constitutes the dermatologic hallmark of this rare genodermatosis. We report a patient who demonstrates the classic findings of Apert's syndrome. Our patient also presented with severe hyperhidrosis, which may represent a new clinical finding not previously reported in association with this syndrome.

Reversible diencephalic dysfunction: episodic hyperhidrosis due to a trapped third ventricle

We present a patient with episodic hyperhidrosis (EH) who had 15 attacks per day for 3 years following placement of a lateral ventricular shunt. MRI revealed that she had an isolated third ventricle. Stereotactic shunting of the third ventricle resulted in immediate and complete resolution of her symptoms. We suggest that this patient had periodic rises in third ventricular pressure resulting in episodic diencephalic dysfunction and EH.

Keratosis extremitatum (Greither's disease): clinical features, histology, ultrastructure

Keratosis palmoplantaris progrediens et transgrediens (Greither's disease) was first described by Greither in 1952. The inheritance pattern is autosomal dominant with variable expression. The clinical manifestation is characterized by diffuse palmoplantar keratoderma associated with hyperhidrosis and progressive extension of keratoderma to the dorsum of the hands and feet. In addition, hyperkeratotic plaques may occur on the elbows and knees. We describe a 44-year-old patient with typical features of Greither's disease. Immunohistologic and ultrastructural investigations are presented.

[Eccrine hamartoma of the sweat glands simulating localized unilateral hyperhidrosis]

We report on the case of a 31-year-old woman who presented with localized unilateral hyperhidrosis on her lower right arm. Histological features showed a hamartoma of the eccrine sweat glands. Because she was afraid of being overweight, the patient took an appetite depressant. Under this self-medication complete cessation of the localized hyperhidrosis was observed.