The efficacy of oral anticholinergics for sympathetic overactivity in a thoracic surgery clinic

Progress and lack of progress in hyperhidrosis research 2015-2020. A concise systematic review

Hyperhidrosis is excessive sweating that is uncontrollable and occurring regardless of temperature. Quality of life is significantly impaired, and psychiatric comorbidity is common. The objective of the study is to undertake a systematic review of research in the last 5 years regarding hyperhidrosis. Five databases were searched from July 2015 to July 2020 for all research on hyperhidrosis. High-quality research articles were sought for progress in diagnosis, etiology and epidemiology, and use of patient reported outcomes (PROs) as well as randomized clinical trials (RCTs) on any treatment intervention. Outcomes of interest were disease severity, sweat rate, quality of life, patient satisfaction, and adverse events. Trial quality was assessed by the Cochrane risk-of-bias tool. A narrative synthesis was presented. Twenty-nine papers were included in the review: 13 investigational articles, 10 RCTs, three cohort studies, and three reviews. The studies varied in terms of quality, population, intervention, and methods of outcome assessment. The majority were very small studies, and most RCTs were at high risk of bias. Few studies on diagnosis, epidemiology, and etiology were of sufficient quality to be presented. The interventions discussed were iontophoresis, botulinum toxin, anticholinergic medication, curettage, and energy-based technologies. Progress in the diagnostics and etiology of hyperhidrosis is limited with the same being true for treatment. In a 5-year-old systematic review, it was concluded that there was moderate-quality evidence to support the use of botulinum toxin for axillary hyperhidrosis. It was advocated to conduct a trial comparing BTX and iontophoresis for palmar hyperhidrosis. Unfortunately, this has not yet been performed. Hyperhidrosis is still as underserved and under-studied as before.

Videothoracoscopic Sympathectomy Results after Oxybutynin Chloride Treatment Failure

BACKGROUND

Videothoracoscopy sympathectomy (VATS) is the only definitive treatment for primary hyperhidrosis (HH). Since 2007, in our institution, patients with HH were initially treated with oxybutynin chloride to avoid VATS and reduce compensatory hyperhidrosis incidence with good results. The aim of this study was to analyze the surgical response of patients suffering from essential hyperhidrosis after failure of oxybutynin chloride treatment.

METHODS

This was an observational retrospective study that included 737 patients who were diagnosed with palmar or axillary hyperhidrosis and received VATS from January 2007 to January 2014. Patients were selected for 2 different groups: The post-oxybutynin surgery group consisted of 167 patients that were initially treated with oxybutynin chloride for 6 weeks and then received VATS after drug treatment failure. The primary surgery group consisted of a historic control group of 570 patients who were referred directly to surgical treatment. We evaluated the degree of improvement in symptoms 30 days after surgery and quality of life before and after the surgical treatment.

RESULTS

All patients showed poor or very poor quality of life before surgery. Most patients showed a response between moderate and high after surgical treatment. However, those in primary surgery group responded better (95.1% vs. 98.2%). In the quality of life after surgery, most of the patients reported improvement, and the primary surgery group had better improvement (92.2% vs. 95.1%).

CONCLUSIONS

VATS showed good results in patients with palmar or axillary hyperhidrosis regarding surgical response and improvement on quality of life even when the previous oxybutynin chloride treatment failed.

CT-Guided, Ethanol Sympatholysis for Primary Axillary-Palmar Hyperhidrosis

PURPOSE

Primary hyperhidrosis is an excessive sweating due to an overactive sympathetic system. Our objective was to test the feasibility and provide early data on the safety/efficacy of CT-guided sympatholysis, for primary hyperhidrosis.

MATERIALS AND METHODS

Nine consecutive patients with axillary-palmar hyperhidrosis were treated between 2013 and 2015. CT-guided sympathetic block was performed in the outpatients at T-2, T-3, and T-4, bilaterally using alcohol under local anesthesia. Immediate postprocedure CT was obtained to assess the complications as per Common Terminology Criteria for Adverse Events, version 4. Technical success and clinical success were recorded. Primary and secondary efficacy were assessed by phone and clinical visits; mean follow-up was 12 months (6-26 months). Descriptive statistics was used to report the outcomes.

RESULTS

One procedure was aborted due to eyelid ptosis after lidocaine injection. All other eight patients (5:3, F:M) (median age 32) had immediate cessation of sweating. Two major complications (pneumothorax, one requiring a chest tube) occurred. Two patients recurred with unilateral and one with bilateral symptoms. One of the unilateral recurrence and the bilateral recurrence patients was retreated successfully. Median follow-up was 1 year. No cases of Horner's or compensatory hyperhidrosis were observed.

CONCLUSIONS

CT-guided EtOH sympatholysis for axillary/palmar primary hyperhidrosis is feasible. Technical failure rate was 11 %. Primary and secondary efficacy are 75 and 94 %, respectively, to a median follow-up of 1 year. Risk profile appears favorable. Despite a small sample size, results confirm feasibility and encourage a larger study.