Skin Adnexectomy

Removing the skin adnexa, or adnexectomy, is a procedure that attempts to remove the skin appendages, such as sweat glands, for conditions such as excessive sweating (hyperhidrosis), malodor (bromhidrosis or osmidrosis), or hidradenitis suppurativa. The goal of the surgery is to reduce these problems long term while minimizing unwanted side effects and complications. Multiple methods to remove the sweat glands in the axillary region have been described.

For more information regarding the treatment of hidradenitis suppurativa, refer to the Medscape Drugs & Diseases topic Surgery for Hidradenitis Suppurativa.

Epidemiology

Hyperhidrosis is increasingly becoming recognized as a significant social and occupational impairment. ^[1]  An estimated 3.12% of the US population is affected by axillary hyperhidrosis. ^[2] Systemic hyperhidrosis that affects the face, palms, soles of the feet, and axilla affects 2.8 million people (2.8% of the population). ^[3] Among patients with axillary hyperhidrosis, one third specified that the excessive sweating frequently interfered with their daily activities. Thus, hyperhidrosis can be a debilitating diagnosis that can impair social and occupational activities. ^{[1, 2]}

No ethnic predilection for hyperhidrosis has been reported; however, multiple studies have described axillary osmidrosis as a significant issue in Far Eastern populations. ^{[4, 5, 6, 7, 8, 9]} Axillary osmidrosis or bromhidrosis is unpleasant odor arising from the axilla, which can cause significant personal discomfort and social impairment, especially in Asian societies. In Western countries, people tend to be primarily concerned with axillary hyperhidrosis, whereas in Asian countries, people seek out treatment for osmidrosis. ^[5]

Individuals with hyperhidrosis may frequently have a family history positive for the diagnosis.

Etiology

Excessive axillary sweating, termed hyperhidrosis, is defined by excessive perspiration greater than the normal physiologic response for the body for thermoregulation. ^[10] Under normal physiologic conditions, sweat glands are stimulated when body temperature elevates, which then produce moisture at the skin surface that may cool the body through the process of evaporation. Sweating may occur episodically, continuously, or seasonally and may be exacerbated by emotions, such as anxiety or nervousness. ^[10] Hyperhidrosis can be divided into primary or secondary. Primary hyperhidrosis has recognizable cause, but many causes of secondary hyperhidrosis have been described, including fevers, metabolic or endocrine disorders, medications, or various physiologic states (eg, menopause, exercise). ^[11]

Pathophysiology

Two main types of sweat glands are recognized: eccrine sweat glands and apocrine sweat glands (see image below).

Both apocrine and eccrine sweat glands are present in the skin of the axilla.

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Eccrine sweat glands are the primary producers of sweat and are located diffusely throughout the skin of the body, with the highest concentrations of glands found in the axilla, palms, and soles of the feet. Eccrine sweat glands secrete sweat through pores located on epidermal ridges and empty directly to the skin surface. Apocrine sweat glands are a subset of glands located in the axilla and genital regions that become active during puberty, under the influence of androgen hormones. ^[4] Apocrine glands secrete sweat into the follicular canal of their associated hair follicles. These glands secrete fluid that is thought to cause offensive odor, which is termed osmidrosis or bromhidrosis when excessive.

In white patients, either all or nearly all eccrine and apocrine sweat glands are not found in the dermis layer in the skin itself but rather within the subcutaneous tissue itself or at the interface of the subcutaneous tissue and the dermis. ^[12] The anatomic location of the sweat glands themselves provides the basis for the various surgical procedures available for the treatment of hyperhidrosis and osmidrosis.

Axillary adnexectomy is indicated for primary hyperhidrosis and for significant osmidrosis. Primary hyperhidrosis has been defined as focal, visible, excessive sweating lasting at least 6 months without apparent cause, with at least 2 of the following characteristics ^[13] :

• Bilateral and relatively symmetric locations

• Impairment of activities of daily living

• Frequency of one or more episode per week

• Age of onset younger than 25 years

• Positive family history

• Cessation of focal sweating during sleep

Although no absolute contraindications to axillary adnexectomy are recognized, several relative contraindications may exist. A thorough attempt at nonsurgical management of hyperhidrosis or bromhidrosis should be tried prior to considering surgical treatment. Patients must also understand the risk of recurrence even after surgical intervention; treatment may have to be repeated or continued.

Patients who have had prior surgical procedures in the axilla, such as sentinel lymph node biopsy or axillary lymph node dissection, may be at a higher risk for developing lymphedema, or painful swelling in the arm. These patients may be at risk for lymphedema with subsequent procedures in the axilla.

Best practices

Before any invasive methods are used, patients should first attempt treatment with easily obtainable over-the-counter antiperspirant or deodorant products. If these products prove inefficacious, stronger clinical strength formulas may be tried as well aluminum chloride products available by prescription. ^[14] Treatment with topical antiperspirants are only temporary of course, with the duration of treatment lasting at most 2-3 days, and frequent reapplication is necessary.

Oral anticholinergic medications are available by prescription and may be effective in treating hyperhidrosis, such as glycopyrrolates. These medications reduce body secretions in the stomach, throat, and nose, as well as the sweat glands and other areas. However their use is associated with multiple side effects, including dry mouth, difficulty urinating, headaches, diarrhea, and constipation, among others. In one study of 24 patients using a glycopyrrolate medication to treat hyperhidrosis, one third had side effects significant enough to limit their treatment. ^[15]

Botulinum toxin injection into the axilla is another method approved by the US Food and Drug Administration (FDA) for the treatment of primary axillary hyperhidrosis and has also been shown to be effective in treatment of hyperhidrosis of the palms of the hands. ^[16] Botulinum toxin injection works by inhibiting the release of the neurotransmitter acetylcholine from the nerves that innervate eccrine sweat glands, which reduces production of sweat. This type of treatment is particularly important in improving the quality of life in children with hyperhidrosis. ^[17]

Botulinum toxin has been shown to begin reducing sweat production within 1-2 weeks of injection, and its effects may last as long as 9 months. ^[18] Botulinum toxin A injection for treatment of secondary axillary bromhidrosis has been reported with success, with effects lasting a median of 6 months (range, 1-12 months). ^[19] Treatment with botulinum toxin is only temporary and must be repeated for continued management of excessive sweating. Pressure jet injection has been used to minimize pain. ^[20]

Potential alternative therapies that show promise include laser treatment for axillary hyperhidrosis, ^[21] topical umeclidinium for primary axillary hyperhidrosis, ^[22] and topical oxybutynin 3% or 10% gel for primary focal hyperhidrosis, ^{[23, 24]} as well as sequential extended thoracoscopic sympathicotomy for palmo-axillo-plantar hyperhidrosis, ^[25] and computed tomography-guided percutaneous ethanol sympatholysis for primary hyperhidrosis. ^[26]

The surgical removal of the sweat glands of the axilla has the potential to provide the patient with hyperhidrosis or osmidrosis a long-lasting and often permanent treatment. Several variations on the technique of removing the sweat glands in the axilla have been shown to be effective and efficacious. ^{[4, 5, 6, 7, 8, 27]}