Progress in the diagnosis and treatment of hand sweating disorder
1.What is hand sweating syndrome?
2.What are the clinical manifestations of hand sweating disorder?
3.Does hand sweating cause any harm to people?
4.What is the diagnosis process of hand sweating?
5.What are the treatment options for hand sweating?
6.How does thoracoscopy treat hand sweating?
7.What are the advantages and disadvantages of thoracoscopic treatment?
8.What is compensatory hyperhidrosis?
9.Why is it necessary to develop new technology for the treatment of hand sweating?
10. What is the principle of thoracic sympathetic block for the treatment of hand sweating?
11. What are the advantages and shortcomings of thoracic sympathetic block in the treatment of hand sweating?
I. What is hand sweating?
Simply put, hand sweating is a symptom of excessive hand sweating, accounting for 0.6% to 1% of the total population.
Sweating is a normal heat dissipation response of the human body and is controlled by the sympathetic nerves in the vegetative nervous system. When the ambient temperature or body temperature exceeds the body’s own temperature set point, the sympathetic nerves become active to prevent the body temperature from rising further, dominating the body’s sweat gland secretion and evaporating through sweat to take away heat to cool down.
Sweating varies from person to person. At the same ambient temperature, some people sweat more and some people sweat less. However, when the ambient temperature is not high and sweating is not normally needed to dissipate heat, but still sweating profusely, it is called “hyperhidrosis”.
Hyperhidrosis is divided into two categories: primary hyperhidrosis and secondary hyperhidrosis.
Primary hyperhidrosis is a state of hypersecretion of the sweat glands with no apparent cause, and is actually a functional autonomic disorder in which the sweat glands are overproducing. Secondary hyperhidrosis is caused by a number of neuroendocrine and other systemic diseases (e.g. hyperthyroidism, diabetes mellitus, hypoglycemia, poisoning, drug side effects, cardiovascular disease, respiratory failure, carcinoid syndrome, Hodgkin’s disease) that cause excessive sweating.
Hyperhidrosis can be divided into generalized hyperhidrosis and localized hyperhidrosis according to the location of sweating. Generalized hyperhidrosis is mostly secondary hyperhidrosis, while localized hyperhidrosis is mostly primary hyperhidrosis.
Hand sweating is actually a primary localized hyperhidrosis and is known to be caused by hyperactivity of the thoracic sympathetic nerve, which governs the secretory function of the sweat glands in both hands.
The first thing you need to do is to get a good idea of what you are getting into.
What are the clinical manifestations of hand sweating?
The main manifestation of primary hand sweating is excessive sweating on the palms of the hands, which is not affected by external temperature. The sweating is usually accompanied by cold palms, and only in a few cases are the fingers kept warm during sweating. Some patients also have sweating on the feet or sweating on the head, face, or armpits.
Sweating is highly correlated with emotional activity, and sweating is more frequent when the mind is under stress. The onset of symptoms is sudden and intermittent, with each episode lasting 5 to 30 minutes and the number of episodes per day varying, but sweating is rare during sleep. Most patients have more severe symptoms in summer and less severe symptoms in winter. In some patients, hand sweating is a frequent occurrence when sweating is thought of, and is much less associated with ambient temperature than with mental activity.
Furthermore, hand sweating often manifests as follows.
A. Plantar sweating: 40% to 45% of people with hand sweating have sweaty soles at the same time, and foot sweat is more likely to accumulate, even if frequent changes of shoes and socks do not remove sweat and its odor in time. Therefore, the soles of the feet are most likely to have secondary skin lesions, such as dermatitis, tinea pedis, skin keratosis off, skin herpes, etc.
B. Axillary sweating: 25%-30% of people with sweaty hands have sweaty axillae, and sweat easily penetrates clothes, and their axillary areas are large sweat patches. Because of the secrecy of the armpit area is also easy to cause the skin bacteria or fungal infection, serious cases of skin erosion.
C. Facial sweating: The combined head and facial sweating accounts for 1% to 5%. Most patients also have facial flushing, and in heavy cases, the face is purplish-red, presenting a nervous and embarrassing appearance.
D. Hands and feet are prone to frostbite: hand and foot sweating is mostly “wet and cold”, and the temperature of the hands and feet is only about 33°C, 2 to 3°C lower than that of those without sweating, thus making them prone to frostbite in winter. Because the hands and feet are often in a state of sympathetic excitation of the constricted blood vessels, hands and feet are often ischemic blue-gray. The hands and feet are often immersed in sweat, and often appear “peeling” phenomenon, occasionally sweat herpes (hands and feet sweating when the sweat duct mouth blockage caused by sweat stored in the palm and toe skin of an eczema-like changes) appear.
In short, primary hand sweating symptoms are typical, the diagnosis is not difficult, but finally to the regular hospital consultation to exclude secondary sweating, symptomatic treatment.
Third, is there any harm to people with hand sweating disorder?
Hand sweating is only a relative excitation of the sympathetic nerves in the human body and is not harmful to health.
However, due to sweaty palms, soles and armpits, it often causes a lot of inconvenience to study, work, life and social activities. For example, when students take exams because the hands sweat a lot easily wet test papers, when operating a computer sweat wet keyboard, engaged in electrical work when wet easy electrocution, social interaction because of the palms of the serious sweaty hands and afraid to shake hands with others ……, and so on, indeed bring a certain amount of trouble to work life.
What is the diagnosis process of hand sweating?
The diagnosis of hand sweating is relatively easy, the key is to distinguish primary hand sweating from secondary hyperhidrosis.
A. Key points of medical history taking.
(1) Determine the exact site of hyperhidrosis and determine whether it is localized or generalized hyperhidrosis.
(2) Frequency and duration of episodes of sweating.
(3) Age of onset.
(4) Family history.
(5) The presence of systemic symptoms such as fever, night sweats, and weight loss.
(6) Whether excessive sweating is associated with emotional activity.
(7) Impact on social, occupational, and daily life.
(8) Exclude other symptoms of secondary hyperhidrosis.
B. Physical examination.
In cases of primary localized hyperhidrosis, only the manifestations of abnormal sweating and positive signs of secondary skin lesions are usually found: e.g. palmar desquamation, sweat rash, frostbite, etc.
Note that some positive signs are found that facilitate the differential diagnosis with generalized hyperhidrosis. For example, wasting may suggest chronic systemic wasting disease, acromegaly may be related to endocrine system disease, those with accelerated heart rate should further exclude the possibility of hyperthyroidism, and those with elevated blood pressure should pay attention to exclude pheochromocytoma.
C. Ancillary tests.
The examination before the diagnosis of hyperhidrosis should also include routine blood and urine examination, as well as the determination of blood glucose, T3 and T4 concentrations. In addition, X-rays or chest CT examinations can exclude the presence of lesions such as tuberculosis in the chest.
CT chest examination should be performed to exclude pleural hypertrophy and other lesions if surgical treatment is planned. In cases where systemic disease is suspected, relevant tests should be performed, such as urine catecholamine derivatives for suspected pheochromocytoma.
V. What treatments are available for hand sweating?
There are a variety of treatments for hand sweating, the most common of which are six types of methods.
① Topical lotions.
Topical lotion is mainly applied with astringent alum, glutaraldehyde and other solutions soaked for tens of minutes, which can have certain effect within a few days, but skin damage of the hands will occur, wrinkling, cracking and other skin lesions, and the effect is not lasting.
②Oral use of anticholinergic antiperspirant.
Systemic use of anticholinergic drugs such as urotropine can inhibit sympathetic nerve activity to some extent, combined with a relative reduction in sweating, but the drug is discontinued that relapse, and the drug is often used during the dry mouth, rapid heartbeat and other complications.
③Anxiolytics for oral use
The episodes of sweating in primary hand sweating are often triggered by emotional activity, especially when the spirit is tense, while sweating does not occur after sleep. For this reason, sedative anti-anxiety drugs can have a certain therapeutic effect. Commonly used drugs are tranquilizers: Valium tablets, Xuloxane tablets, Imipramine tablets, Synthroid tablets, anxiolytic Amitriptyline tablets, Prozac, Dalixin, etc. But sedative anti-anxiety drugs often cause mental depression, tiredness, inattention. The long time to take also appears drug dependence, and therefore less used in the treatment of hand sweating.
④ Local injection of carnitine.
Carnitine palm surface skin injection within the injection can make the injection site to stop or reduce sweating within 1~3 months. However, this method is painful, requires multiple injections, repeated injections, and is prone to complications such as palmar surface infection, and costs high Pleiades, each hand injection treatment costs nearly $1,000, and can only be effective for 1~3 months.
⑤ Surgical treatment.
Traditional open-chest surgery to cut off the thoracic sympathetic chain to treat hand sweating began in 1954, by Kux first open-chest resection of T2 to block sweat gland secretion was successful, but because of the huge open-chest trauma, promotion difficulties (the traditional surgical approach is to cut from the center of the back and remove the second and third sympathetic ganglion on both sides, this method of surgery time, recovery time is long, risky, there is a postoperative wound of about five to seven centimeters)
Since the use of Endoscopic Thoracic Sympathectomy (ETS) for hand sweating in 1992, this procedure has become the “gold standard” for the surgical treatment of hand sweating: one to three small incisions in each side of the axilla, each about 1 to 2 cm. The operation time and recovery period is shorter than traditional open-heart surgery, and the pain is also lighter than traditional surgery, but the operation still requires general anesthesia and is more expensive (more than 10,000 yuan). At present, this procedure is more carried out in China and the technology is more mature, and basically all tertiary hospitals with thoracoscopy around the country can carry out it.
(6) Minimally invasive interventional treatment —- CT-guided percutaneous percutaneous thoracic sympathetic nerve block.
This technique is a new, more minimally invasive treatment for hand sweating developed by Jiaxing First Hospital in 2009. No incision or general anesthesia is required, and two fine needles are punctured from behind to the vicinity of the sympathetic nerve under CT guidance, and 2 ml of anhydrous alcohol is injected to cure the hand sweating.
The new method is nearly non-invasive and can walk as usual with good treatment and costs only about 4,000 yuan. It has cured a group of patients from Shaanxi, Hubei, Xinjiang and Jiaxing, and has been reported in Nanhu Evening News (May 30), Jiaxing Daily (June 1) and Health News (June 15), which is a more promising method.
Sixth, how does thoracoscopy treat hand sweating?
Although the exact mechanism of primary hand sweating has not been completely clarified, it is clear that excessive thoracic sympathetic nerve activity is directly related to the occurrence of hand sweating. The effectiveness of cutting the thoracic sympathetic nerve chain in the treatment of hand sweating has been clinically proven.
Following conventional open-heart surgery to cut the thoracic sympathetic nerve for hand sweating, televised thoracoscopic thoracic sympathectomy (ETS) has become a classic procedure for the treatment of hand sweating.
An anesthesiologist first administers general anesthesia to the patient with hand sweating, and a double-lumen tracheal tube is inserted to ensure that both lungs can be ventilated separately. The surgeon makes one to three small incisions of about 2 cm in the axillary area, and the anesthesiologist controls the patient to ventilate one lung on the opposite side, while the lung on the operated side is completely atrophied, exposing the chest cavity completely. The electrocautery is performed on the thoracic sympathetic chain at T2 to T4 to sever the sympathetic chain at these locations. Subsequently, the hemorrhage is stopped, the lens is removed, the anesthesiologist bulks the lung, and a closed chest drain is placed, followed by the same method of severing the sympathetic chain in the contralateral thorax.
After the operation, the anesthesiologist stops the drugs and removes the tracheal tube when the anesthesia is fully awakened. The patient can speak after further resuscitation and can get out of bed after one day. Generally, the patient can be discharged from the hospital three days after surgery and the incision sutures can be removed in five to ten days.
After the thoracic sympathetic nerve chain is severed, the hand sweating phenomenon can disappear immediately and can be stopped for life. However, some patients will have compensatory hyperhidrosis after surgery, i.e. hand sweating does not occur anymore, but sweating in the chest, abdomen, waist and back and thighs is much more than before.
VII. What are the advantages and disadvantages of thoracoscopic treatment?
The advantages of thoracoscopic treatment for hand sweating are
A. Compared with conventional open-heart surgery, thoracoscopic incision is small and trauma is significantly reduced, which is favorable to patients’ postoperative recovery.
B. The TV thoracoscope is an instrument with a camera lens that is inserted into the pleural cavity, and the situation of the pleural cavity is recorded on the TV screen at the side of the operating table, which is equivalent to cutting the thoracic sympathetic nerve with an electric knife under “bright vision”, with accurate operation and precise efficacy.
C. The operation is performed under general anesthesia in the operating room, and in the event of bleeding, pneumothorax and other complications, hemostasis and drainage can be performed at any time.
Shortcomings of thoracoscopic treatment of hand sweating.
A. Although it is much less traumatic compared with conventional open-chest surgery, it still requires 2~6 incisions, and the incisions need to be sutured after the operation. The postoperative pain is more intense, and it takes at least 5~15 days to recover to normal, and the incisions may also leave more obvious scars.
B. The surgery is performed under general anesthesia, a double-lumen tracheal tube needs to be inserted, and intraoperative one-lung ventilation is required. Patients are at risk of carbon dioxide accumulation and hypoxemia, as well as other anesthesia-related risks.
C. There are relative contraindications. Thoracoscopic surgery must be performed through the pleural cavity. If the patient has pleurisy or pleural hypertrophy, adhesions, or other pleural cavity disease, thoracoscopic surgery will have to be abandoned because the thoracic sympathetic nerve cannot be exposed. That is, such patients cannot complete the procedure thoracoscopically. In addition, limited to the type of double-lumen tracheal tube, patients with thin trachea or with tracheal stenosis will also be unable to receive thoracoscopic surgical treatment due to the difficulty of double-lumen tube intubation.
D. The procedure is risky and has more possible complications. Possible complications include hemothorax due to bleeding in the chest or pneumothorax due to rupture of lung membranes and alveoli. Very few patients will have Horner’s syndrome (mild drooping of the eyelids), a complication that affects the aesthetics but not the vision, and if this complication is permanent, cosmetic surgery is required to correct it. Other potential hazards, as with any surgery, such as allergy to anesthetic drugs, are possible, and there are rare reports in the literature of injuries causing celiac disease and large blood vessels.
E. Postoperative compensatory sweating is a problem that has not yet been cracked in thoracoscopic treatment of hand sweating. After thoracic sympathetic nerve severance, the sympathetic nerve below the severed end loses downward inhibition from the higher center (brain), resulting in increased uncontrolled autonomic activity and thus a large increase in sweating in the abdomen, thoracic back, and both lower extremities, a complication that most patients can tolerate, but which more than 25% of patients find unbearable and may even regret having undergone surgical treatment. Although the compensatory sweating of many patients will gradually decrease with the prolongation of postoperative time, it also brings new troubles to some postoperative patients.
F. Special equipment is required, medical resources are occupied and medical costs are high. This treatment is necessary to have a TV chest unit to carry out, and the thoracoscopic equipment is mostly over one million yuan, and many tertiary hospitals do not have this equipment yet. When carrying out this operation, 5~8 medical personnel are required to participate at the same time, which occupies large medical resources. Together with the operation fee, anesthesia fee, and hospitalization fee, the cost of thoracoscopic thoracic sympathectomy for hand sweating is more than ten thousand yuan.
VIII. What is compensatory hyperhidrosis?
Compensatory hyperhidrosis refers to a condition in which part of the body surface is asymmetrically hypersecreted by sweat glands after some areas of the body surface have been rendered sweat-free by lesions or surgery. Compensatory hyperhidrosis can be caused by sympathetic trunk injury (including sympathectomy), spinal cord injury, and diabetic neuropathy.
It is currently believed that compensatory hyperhidrosis after thoracic sympathetic chain severance is due to the loss of downward inhibition of sympathetic nerves below the severed end of the chain by the higher center (hypothalamus), resulting in abnormally increased sympathetic activity.
This is reflected in an increase in sweating on the torso, especially on the back and thighs, after the surgery to release sweating on the palms of the hands and face. In addition, once thoracic sympathectomy is performed, if there is significant compensatory sweating after the surgery, it is impossible to restore the sweating to the original condition before the surgery or by other means.
Thus, compensatory sweating is one of the challenges of thoracoscopic surgery for hand sweating that has yet to be solved. In general, patients with mild to moderate compensatory hyperhidrosis after surgery can still accept it, but a few patients with severe compensatory hyperhidrosis do bring new and serious problems to their lives.
IX. Why is it necessary to develop new techniques for the treatment of hand sweating?
Although the efficacy of thoracoscopic surgery for hand sweating is exact, it still has greater trauma and related complications and risks, plus it requires special equipment, takes up a lot of medical resources, and has high treatment costs, which also makes some of the less well-off hand sweaters have to endure the inconvenience caused by hand sweating and cannot receive thoracoscopic surgery.
In addition, postoperative compensatory hyperhidrosis is a problem that has not yet been solved by thoracoscopic surgery. This is because once the thoracic sympathetic nerve is disconnected by thoracoscopic electrocautery, it is very difficult to reattach it. In other words, if compensatory hyperhidrosis occurs after surgery, there is currently no way to solve this problem.
So can a more minimally invasive, economical and safe treatment technique be developed?
The answer is yes. Because the development of medical technology suggests that there is no end to the minimally invasive means of treatment, i.e., still any kind of treatment technology is only better, not the best. The replacement of traditional open-heart surgery by thoracoscopy is a better approach and has become the “gold standard” for the treatment of hand sweating, but it is also time-sensitive, i.e., thoracoscopic surgery is the best approach in this era, and there will certainly be better ways to replace it in the future.
CT-guided percutaneous thoracic sympathetic nerve block technique for hand sweating is more minimally invasive, more economical, and can avoid or reduce the occurrence of compensatory hyperhidrosis, and is expected to become the next “gold standard” for the treatment of hand sweating after thoracoscopic surgery.
X. What is the principle of “CT-guided percutaneous thoracic sympathetic block” for hand sweating?
In order for a nerve to work properly, it must have structural and functional integrity. Once the structure of a nerve is destroyed, it loses its basic function; similarly, if a drug is used to block the conduction of a nerve, it will lose its function, even if its structure is intact. The simplest example is nerve block anesthesia (e.g., lumbar anesthesia or brachial from nerve block), where a local anesthetic is administered to the subarachnoid space or near the brachial plexus nerve, allowing the drug to temporarily block the conduction function of the nerve, so the lower body or upper extremity is paralyzed, as if it were paraplegic. However, the local anesthetic is short-lived, wearing off in a maximum of 10 hours or so, and the function of the nerve is restored.
Unlike thoracoscopic thoracic sympathectomy, CT-guided percutaneous thoracic sympathetic block technique does not break the nerve, but blocks the function of the nerve. Only the short-acting local anesthetic is replaced with anhydrous alcohol that can be effective for a long time.
In other words, the thoracic sympathetic block technique preserves the structural integrity of the thoracic sympathetic nerve and achieves the goal of treating hand sweating by blocking the function of the nerve. That is, the activity of the sympathetic nerve is reduced by injecting anhydrous alcohol near the thoracic sympathetic nerve instead of cutting it off.
XI. What are the advantages and disadvantages of thoracic sympathetic block in the treatment of hand sweating?
The advantages of thoracic sympathetic block in the treatment of hand sweating are
A. It is more minimally invasive. This technique can be done by sticking two fine needles into the back under CT guidance to inject drugs near the thoracic sympathetic chain, without surgery, without general anesthesia, without incisions, without scars, and the patient can get up and leave after treatment.
B. More economical. This technology only requires one imaging doctor and one puncture injection doctor in the CT room to complete the treatment operation, getting rid of the reliance on thoracoscopic equipment and general anesthesia, greatly saving medical resources, the whole treatment cost is only about 4,000 yuan, and the treatment can be completed without hospitalization.
C. It can achieve the same effect as thoracoscopic surgery. Although the thoracic sympathetic nerve is not cut, the activity of the thoracic sympathetic nerve is blocked, and the same treatment effect as thoracoscopic surgery can be achieved.
D. The integrity of the thoracic sympathetic nerve structure is still intact, which creates conditions for later recovery of nerve function. Once the nerve is severed, the possibility of recanalization is very small. In other words, if severe compensatory hyperhidrosis occurs after thoracoscopic surgery, the doctor may be helpless; whereas thoracic sympathetic block therapy preserves the structural integrity of the nerve, only blocking its activity, in case of severe compensatory hyperhidrosis, there is still a possibility of nerve repair. Once the nerve is repaired, the problem of compensatory hyperhidrosis will be solved.
E. The blocking operation can be repeatedly performed. Thoracoscopic thoracic sympathetic neurectomy needs to be operated through the pleural cavity, and postoperative pleural adhesions are inevitable. If the result is poor or recurrence, it is basically impossible to perform thoracoscopic surgery again. However, nerve block can be repeatedly performed, and even if there is a recurrence of hand sweating, it can be easily treated with another block.