eMedicine Specialties > Plastic Surgery > Skin

Surgical Treatment of Axillary Hyperhidrosis

Author: Richard H S Karpinski, MD, FACS, Assistant Clinical Professor, Department of Surgery, Columbia University College of Physicians and Surgeons; Senior Attending, Department of Surgery, St Luke's/Roosevelt Hospital
Contributor Information and Disclosures

Updated: Jul 17, 2009

Introduction

Primary hyperhidrosis is excessive uncontrollable sweating without any discernible cause. It most commonly involves the axillae, palms, and soles but may also involve the face and groin.

Secondary hyperhidrosis may be caused by endocrine disorders (eg, hyperthyroidism), secretory tumors (eg, pheochromocytoma), sympathetic nervous system disorders, or primary neurologic or psychiatric disorders.

Surgical treatment of axillary hyperhidrosis. Mod...

Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Preoperative axilla in a healthy young writer with axillary hyperhidrosis. Image courtesy of Richard H S Karpinski, MD.

[ CLOSE WINDOW ]
Surgical treatment of axillary hyperhidrosis. Mod...

Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Preoperative axilla in a healthy young writer with axillary hyperhidrosis. Image courtesy of Richard H S Karpinski, MD.

Frequency

The incidence of hyperhidrosis is uncertain, but Adar's study of a young Israeli population reported a prevalence of 0.6-1% for palmar hyperhidrosis; familial involvement was reported in 25% of patients.1 The incidence of axillary hyperhidrosis is believed to be similar.

Etiology

Etiology of axillary hyperhidrosis is unknown but is related to increased cholinergic sympathetic stimulation of the sweat glands in the axilla. Although the glands invariably become remarkably hypertrophied in this condition, the dramatic glandular growth and oversecretion is believed to be secondary rather than primary; a parallel concept is oxyntic cell hypertrophy in peptic ulcer disease due to vagal hypertonicity.

The observed atrophy of sweat glands in grafted (thus denervated) skin, with reappearance of sweating with reinnervation, led to the conceptual link between sympathetic tone and acinar hypersecretion. Further evidence of the neural control of sweat production comes from the observation that local anesthetic injection transiently stops hypersecretion of sweat as does cholinergic blockade from local injection of botulinum toxin.

While axillary hyperhidrosis almost always begins with puberty, no direct hormonal connection has been suggested.

Several related axillary conditions may be confused with hyperhidrosis.

Axillary bromidrosis (or osmidrosis) is chronic offensive axillary odor; it may be related to apocrine secretions and to chronic bacterial colonization (especially with diphtheroids and micrococci), and antibiotic treatment may be suppressive or curative.

Axillary lymphadenitis is the inflammation and enlargement of underarm lymph nodes.

Axillary hidradenitis is chronic recurring infection of the apocrine sweat glands, manifested by production of repeated boils and sinuses. Once established, the condition may be suppressed, but not cured, by antibiotics. Excision of the involved skin and glands is the only cure; such resections are generally quite disfiguring. The exact cause is unknown, but a hormonal influence appears to be involved.

An axillary breast is the presence in the axilla of subcutaneous breast tissue with or without a nipple.

Pathophysiology

Histology

Bisbal et al have determined that eccrine and apocrine sweat glands are mixed in the axilla, with a proportion of 1:1.2

In patients with axillary hyperhidrosis, Morgan and Hughes demonstrated that the apocrine glands are significantly larger and more numerous than those in axillary hidradenitis and in healthy control subjects.3

Following a thorough resection of the subcutaneous axillary sweat glands (Skoog procedure), a few eccrine glands remain, and practically no apocrine glands can be found.

Thus it seems that a Skoog adenectomy is essentially an apocrinectomy. This is at odds with the observation that the profuse sweat produced in axillary hyperhidrosis (and stopped by Skoog resection) is clear and odorless; classically, apocrine sweat is described as cloudy and odoriferous, while eccrine sweat is labeled clear and without odor. No one has reconciled these seeming inconsistencies, but the inference is that the clear, odorless, profuse sweating observed in axillary hyperhidrosis comes from the hypertrophied and overactive apocrine glands.

Presentation

Patients with axillary hyperhidrosis usually complain of constant or frequent sweating, with streams of wetness running down their sides. This diathesis wets and ruins clothing and produces social embarrassment or functional problems from skin maceration. Severely affected patients also may have secondary microbial infections. Unlike functional sweating, which may be triggered by exercise, exertion, or high temperature, hyperhidrosis may require no trigger at all or may be stimulated by emotional situations and/or anxiety. Most patients with axillary hyperhidrosis have tried multiple antiperspirants and various medications and often have devised various coping methods involving clothing strategies. Many have consulted various physicians, often to no avail.

Some patients may have unilateral axillary hyperhidrosis or a more severe diathesis on one side than the other. Many patients with axillary hyperhidrosis also are afflicted with palmar, facial, or plantar hyperhidrosis to some degree.

The problem usually begins with puberty but also may present in mid childhood, especially in Asian populations.

Contraindications

As with any invasive treatment of a non—life-threatening condition, the risks of axillary hyperhidrosis surgery need to be low. Any health condition that substantially increases the surgical risk may make a recommendation for such surgery inappropriate.

Pulmonary or cardiac pathology may make thoracic surgery, even endoscopic thoracic surgery, too dangerous for the nature of the problem. Problems with skin circulation (eg, lupus) or situations known to degrade wound healing (eg, steroid treatment, previous radiation therapy, diabetes) may make the risk of surgery unacceptable.

Patients with only (or predominantly) axillary hyperhidrosis probably should not be steered toward endoscopic transthoracic sympathectomy (ETS). Patients with multiple hyperhidrotic sites should strongly consider ETS before Skoog adenectomy.

More on Surgical Treatment of Axillary Hyperhidrosis

Overview: Surgical Treatment of Axillary Hyperhidrosis
Workup: Surgical Treatment of Axillary Hyperhidrosis
Treatment: Surgical Treatment of Axillary Hyperhidrosis
Follow-up: Surgical Treatment of Axillary Hyperhidrosis
Multimedia: Surgical Treatment of Axillary Hyperhidrosis
References
[ CLOSE WINDOW ]

References

  1. Adar R. Surgical treatment of palmar hyperhidrosis before thoracoscopy: experience with 475 patients. Eur J Surg Suppl. 1994;(572):9-11. [Medline].

  2. Bisbal J, del Cacho C, Casalots J. Surgical treatment of axillary hyperhidrosis. Ann Plast Surg. May 1987;18(5):429-36. [Medline].

  3. Morgan WP, Hughes LE. The distribution, size and density of the apocrine glands in hidradenitis suppuritiva. Br J Surg. Dec 1979;66(12):853-6. [Medline].

  4. Heckmann M, Ceballos-Baumann AO, Plewig G, et al. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. Feb 15 2001;344(7):488-93. [Medline].

  5. Minor V. Ein neues Verfahren zu der klinischen Untersuchung der Schweissabsonderung. Dtsch Z Nervenheilkd. 1928;101302-7.

  6. Shelley WB, Hurley HJ Jr. Studies on topical antiperspirant control of axillary hyperhidrosis. Acta Derm Venereol. 1975;55(4):241-60. [Medline].

  7. Lillis PJ, Coleman WP 3rd. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin. Jul 1990;8(3):479-82. [Medline].

  8. Shenaq SM, Spira M, Christ J. Treatment of bilateral axillary hyperhidrosis by suction-assisted lipolysis technique. Ann Plast Surg. Dec 1987;19(6):548-51. [Medline].

  9. Ellis H. Axillary hyperhidrosis: failure of subcutaneous curettage. Br Med J. Jul 30 1977;2(6082):301-2. [Medline].

  10. Skoog T. Excision of the axillary sweat glands. In: Plastic Surgery, New Methods and Refinements. Philadelphia, Pa: WB Saunders Co; 1974.

  11. Arneja JS, Hayakawa TE, Singh GB, et al. Axillary hyperhidrosis: a 5-year review of treatment efficacy and recurrence rates using a new arthroscopic shaver technique. Plast Reconstr Surg. Feb 2007;119(2):562-7. [Medline].

  12. Herbst F, Plas EG, Fugger R, Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations. Ann Surg. Jul 1994;220(1):86-90. [Medline].

  13. Park DH, Kim TM, Han DG, Ahn KY. A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures. Ann Plast Surg. Nov 1998;41(5):488-97. [Medline].

  14. Atkins JL, Butler PE. Hyperhidrosis: a review of current management. Plast Reconstr Surg. Jul 2002;110(1):222-8. [Medline].

  15. Atkins JL, Butler PE. Treating hyperhidrosis. Excision of axillary tissue may be more effective. BMJ. Sep 16 2000;321(7262):702; author reply 703. [Medline].

  16. Chiou TS, Chen SC. Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis. Br J Surg. Jan 1999;86(1):45-7. [Medline].

  17. Freeman R, Waldorf HA, Dover JS. Autonomic neurodermatology (Part II): Disorders of sweating and flushing. Semin Neurol. Dec 1992;12(4):394-407. [Medline].

  18. Goldwyn RM. Editorial: The treatment of axillary hyperhidrosis. Arch Surg. Jan 1976;111(1):13. [Medline].

  19. Gossot D, Galetta D, Pascal A. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg. Apr 2003;75(4):1075-9. [Medline].

  20. Guttmann L. A demonstration of the study of sweat secretion by the quinazarin method. Proc R Soc Med. 1941;35:77-8.

  21. Hamm H, Naumann MK, Kowalski JW, Kutt S, Kozma C, Teale C. Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology. 2006;212(4):343-53. [Medline].

  22. Heckmann M. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery. Jun 1998;42(6):1403-4. [Medline].

  23. Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. Aug 2004;51(2):274-86. [Medline].

  24. Hund M, Kinkelin I, Naumann M, Hamm H. Definition of axillary hyperhidrosis by gravimetric assessment. Arch Dermatol. Apr 2002;138(4):539-41. [Medline].

  25. Karpinski RHS. Axillary hyperhidrosis: treatment by excision or by suction adenectomy. Abstract presented at: Northeastern Society of Plastic Surgeons Annual Meeting; Sep 1990.

  26. Lawrence CM, Lonsdale Eccles AA. Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis: a retrospective clinical and histological review of 15 patients. Br J Dermatol. Jul 2006;155(1):115-8. [Medline].

  27. Mack GW, Shannon LM, Nadel ER. Influence of beta-adrenergic blockade on the control of sweating in humans. J Appl Physiol. Nov 1986;61(5):1701-5. [Medline].

  28. Murphy R, Harrington CI. Treating hyperhidrosis. Iontophoresis should be tried before other treatments. BMJ. Sep 16 2000;321(7262):702-3. [Medline].

  29. Odia S, Vocks E, Rakoski J, Ring J. Successful treatment of dyshidrotic hand eczema using tap water iontophoresis with pulsed direct current. Acta Derm Venereol. Nov 1996;76(6):472-4. [Medline].

  30. Reinauer S, Neusser A, Schauf G, Holzle E. Iontophoresis with alternating current and direct current offset (AC/DC iontophoresis): a new approach for the treatment of hyperhidrosis. Br J Dermatol. Aug 1993;129(2):166-9. [Medline].

  31. Skoog T, Thyresson N. Hyperhidrosis of the axillae, a method of surgical treatment. Acta Chir Scand. 1962;124:531-8.

  32. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. Aug 2004;51(2):241-8. [Medline].

  33. Wang HJ, Cheng TY, Chen TM. Surgical management of axillary bromidrosis--a modified skoog procedure by an axillary bipedicle flap approach. Plast Reconstr Surg. Sep 1996;98(3):524-9. [Medline].

  34. Wu WH, Ma S, Lin JT, et al. Surgical treatment of axillary osmidrosis: an analysis of 343 cases. Plast Reconstr Surg. Aug 1994;94(2):288-94. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

excessive underarm sweating, bromidrosis, osmidrosis, idiopathic hyperhidrosis, essential hyperhidrosis, primary hyperhidrosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Richard H S Karpinski, MD, FACS, Assistant Clinical Professor, Department of Surgery, Columbia University College of Physicians and Surgeons; Senior Attending, Department of Surgery, St Luke's/Roosevelt Hospital
Richard H S Karpinski, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Shahin Javaheri, MD, Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery
Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC
Wayne Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Gregory Caputy, MD, PhD, FICS, Chief Surgeon, Aesthetica Plastic and Laser Surgery Center, Inc
Gregory Caputy, MD, PhD, FICS is a member of the following medical societies: American Medical Association, American Society for Laser Medicine and Surgery, Canadian Medical Association, Hawaii Medical Association, International College of Surgeons, International College of Surgeons US Section, Pan-Pacific Surgical Association, and Wound Healing Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.