1. What is the medical name for excessive sweating (hyperhidrosis) and what are the most common causes?
First of all, I would like to talk briefly about the physiology of normal sweating. Namely, sweat glands normally play an important role in regulating body temperature to keep it within the normal range.
There are two types. The eccrine sweat glands, which are commonly found in the body, provide watery sweating with the orders they receive from the nerves. There are also apocrine sweat glands located in the armpits and groin. They have the same embryological origin as hair follicles and sebaceous glands.
They are stimulated to sweat by hormones, not by nerves. The sweat from these glands is odorous and has a thicker consistency. In children before puberty, these glands do not work because certain hormones are not yet active and therefore their sweat does not smell bad.
The region in the brain called the hypothalamus plays the most important role in temperature regulation.
In cases of excessive physical activity (such as exercise), hot weather or fever caused by infection, sweating occurs mainly by sending nerve impulses to the eccrine sweat glands, bringing the body temperature to normal ranges. This is the basis of the sweating system with heat stimulation.
In addition, sweating glands can also be stimulated by emotional stimuli. We have all experienced it, for example, when we make a clumsy move in a crowded and formal environment or during an important speech in front of the public, there may be a sweating triggered by our emotions. This is where sympathetic cholinergic nerve impulses come into play. The control mechanism in this emotional sweating is not controlled by the hypothalamus, but by the cortex of the brain.
what is this sympathetic nerve impulse?
It is actually part of a perfect system that we have been given to protect our bodies. We are all born to live in the wild. For example, when we encounter an aggressive animal, our pupils dilate, blood vessels to internal organs such as the stomach constrict, and blood flow to the legs such as the leg muscles increases.
In fact, the aim here is to make the necessary preparations to escape from that animal. This system, which works reflexively without us thinking, is called the sympathetic system. There is also the opposite, the parasympathetic system. For example, when we sleep, or when we listen to soft music in a quiet environment, we experience the opposite effects of the sympathetic system. Our muscles relax, our pupils shrink and we become ready for sleep. This allows us to rest and regenerate.
Another type of sweating is what we call "gustatory sweating", which can occur when eating (especially hot and spicy food). There are several opinions on this. One is that the body temperature rises due to the acceleration of metabolism during meals. The other is that the substance called "capsaicin", especially in pepper, stimulates the temperature receptors in the mouth, i.e. sensory receptors, as if they were exposed to heat, stimulating the hypothalamus in the brain to lower the temperature.
The other idea is that "capsaicin" stimulates pain receptors, i.e. sensory receptors, resulting in sweating as a result of activation of the sympathetic system.
So in summary, 3 mechanisms play a role in sweating:
• Temperature regulation,
• Emotional state (sympathetic-parasympathetic system activation and hormonal changes are also included in this group)
• Sweating triggered by meals.
Depending on a problem related to one of these mechanisms, some people may have excessive sweating beyond the normal need. We call this "hyperhidrosis" in medical language.
As for the causes of hyperhidrosis, hyperhidrosis is divided into two in this respect.
• Essential (Primary Hyperhidrosis): There is no known underlying cause. The person may sweat excessively.
• Secondary hyperhidrosis: Occurs as a result of an underlying disease. Underlying conditions that cause secondary hydrosis include diabetes, goiter (high thyroid hormone levels - hypertrophy), hypoglycemia (excessively low blood sugar), pheochromocytoma (a tumor of the adrenal gland that causes excessive hormone secretion), The main ones are acromegaly (overgrowth of the limbs), carcinoid syndrome (hormonal imbalance caused by the presence of a tumor called carcinoid in the body), congestive heart failure, chronic lung diseases, febrile infections, Parkinson's disease, psychiatric problems. Sometimes it can be a side effect of medication or as a result of alcoholism or substance abuse.
2. What are the effects of excessive sweating on quality of life?
Before answering this question, I would like to explain one more situation. In the previous question, we divided excessive sweating into two as primary or secondary according to its causes. Based on this question, I divide it into two in a different way. As regional or diffuse sweating...
If excessive sweating is seen all over the body and equally, we call it generalized sweating. However, it can also be seen as excessive sweating only in certain parts of the body. This is called focal hyperhidrosis. Focal hyperhidrosis can basically take 3 forms.
• As we explained in the previous question, gustatory, that is, triggered by food, can only be on the forehead or only on the face. I am skipping this because I explained it in the previous question.
• Secondarily, that is, regional excessive sweating can be observed due to an underlying cause. This cause is neurological, that is, it is seen due to a disorder in our nervous system and excessive sweating can be observed in the skin area controlled by that nerve. Neurological diseases that cause this condition occur as a result of neuropathies or spinal cord injuries.
• The third item is our main area of interest. Primary, that is, excessive sweating that occurs only in certain areas without an underlying cause. These conditions may involve one, more than one or all four of hand, face, armpit or foot sweating. However, apart from these areas, there is no other part of the body that sweats excessively.
Now back to your question: excessive sweating can of course cause many problems for the quality of life. The area in which it appears is also important for this. For example, I have seen excessive sweating of the hands cause a school-age child to wet his exam paper and as a result, his exam was invalidated. Or, for example, a person who needs to shake hands for his job and constantly wet hands can prevent him from doing his job.
Excessive facial sweating can put a person in a difficult situation in social situations or make them the subject of ridicule. Excessive foot sweating can lead to smelly shoes and other social problems. Excessive sweating in the armpits can cause the person's clothes to get wet in those areas, causing an unattractive appearance.
Apart from this, generalized sweating is a big problem in itself. Imagine how uncomfortable it would be to walk around soaking wet, right?
3. Is excessive sweating associated with other health problems?
I think I answered this question while explaining the concepts of primary and secondary hyperhidrosis in the first question. Those who want can look at my answer in question 1 for this.
4. In which cases is surgical intervention recommended for excessive sweating?
As I explained in questions 1 and 2, surgical treatment is the first treatment to be applied in primary and regional hyperhidrosis.
In other words, in general, the scientific literature on all health problems plans treatments from the less interventional to the more interventional. In other words, medication first, if it cannot be solved with medication, solving the problem with a catheter, if that does not work, applying an intervention such as endoscopy without making any incision, if this is not a solution, closed surgery, if this is not a solution, open surgery.
The only problem I have encountered in the medical literature that is the opposite of this is the treatment of primary regional hyperhidrosis. Because clearly the most successful treatment of this condition is Sympathectomy surgery. For this surgery, the least invasive closed surgery, that is, endoscopic thoracic sympathectomy or ETS, is applied.
The aim of sympathectomy is to find a solution to this sweating problem by deactivating the part of the sympathetic nerve that goes to the sweating area, the mechanism of which I explained in Question 1.
5. In terms of thoracic surgery, what are the surgical methods used in the treatment of excessive sweating?
In ETS surgery, only one incision of 1 or 2 cm each is made on both axillary folds of the patient, i.e. the armpit line, and a camera is inserted into the chest cavity. With the help of this camera, sympathetic nerves are seen with long instruments extended through the same incision. 1,2 or 3 sympathetic nerves are cut in accordance with the region of sweating and the procedure is terminated.
The procedure takes less than 1 hour in total, including both sides. No drain or other catheter is placed after the operation. It is almost impossible to understand that the patient has undergone surgery, as only a fingertip-sized line mark coincides with the line that already exists there, as it coincides with the armpit fold. Patients are discharged from the hospital on the day of the procedure and a very comfortable and painless procedure is completed.
I believe that the ease of the operation plays an important role in the prioritization of surgical treatment in the scientific literature.
6. What factors are considered when deciding on surgical treatment?
First of all, we try to understand whether excessive sweating is primary or secondary. We ask questions about whether the patient has any other underlying disease. We also look at the blood tests and other examinations he/she has had before.
We evaluate whether there is anemia, hypertrophy, other biochemical disorders, diabetes. If we see that there is no organic disorder as a result of all these examinations, then we think that it is primary hyperhidrosis. However, we are not satisfied with this. There are diagnostic criteria for Primary Focal (regional) Hyperhidrosis and I ask trap questions to the patients regarding those diagnostic criteria.
For example, I explained in Question 1 that the sympathetic nervous system does not work during sleep, so I ask the patient if he/she sweats during sleep. If he/she says that he/she does, I direct the patient to alternative treatments, anticipating that he/she will not benefit from the surgery since the cause of this sweating is not the excessive activation of the sympathetic system.
In other words, which patient will benefit and at what rate is a bit related to the physician's experience in this field. However, with the right patient selection, I have personally achieved 100% success so far.
7. How should patients be prepared before surgical intervention?
The routine procedures applied in every surgery are sufficient. In other words, if there is smoking, it is sufficient for us to have the patient quit at least 3 weeks ago, to evaluate the patient with routine blood tests and chest radiography and to obtain anesthesia approval.
8. What are the risks and complications of excessive sweating surgery?
Yes, this is the part that we inform every patient at length. Risks such as low probability bleeding and infection that may occur in every thoracic surgery are also valid for this surgery. However, I think you are asking about the ones specific to this surgery.
The biggest regret of this surgery, a side effect, is reflex sweating. This reflex sweating is the complete recovery of sweating in the target area, for example in the hand, but excessive sweating starts at any level below an imaginary line connecting both nipples, for example around the navel or on the back.
Although theoretically it is stated to be reversible, in practice it is irreversible. The rate is around 40%. The risk increases as the number of nerves cut increases. I talk about this subject with my patients for a long time.
However, we perform this surgery when a student individual accepts this risk by saying that I can tolerate the one around the navel, as long as the sweating in my hand passes and my exam papers do not get wet.
Because reflex sweating is unpredictable, it is caused not by a problem in the operation, but by the body's reaction to the cutting of the nerve. Therefore, it is not a situation that we can prevent. In addition to the expected side effects, there are also unexpected complications. The most important situation is the possibility of a drooping eyelid on one side. We call this "Horner's Syndrome" in the medical literature.
The risk is slightly higher especially in surgeries performed for facial sweating. However, this risk is around 1%, it is not an expected situation like a reflex sweating. Therefore, it is seen as a complication, not a side effect. It is mostly reversible.
However, in case it is permanent, the patient may have to undergo a separate aesthetic surgery for the eyelid. I have had it in 1 patient so far, and it resolved spontaneously within 2 weeks. So I can say that the 1% rate in the literature is quite pessimistic in this regard...
Other side effects and complications are less important. For example, there is a condition called phantom sweating. The patient feels that he/she is sweating despite the surgery, but he/she is not sweating. Others like this are insignificant conditions that can be tolerated. I have explained the important ones.
9. How long does the recovery period after surgery usually take?
Patients can be discharged on the day of surgery. On the 3rd day, we allow them to open their wound dressings and leave them open. After this process, they take their baths by sticking waterproof tape for 1 week and bathing is also free from the 10th day. They can return to their daily lives the day after surgery. I can say that it is a painless and comfortable surgery.
10. Are there cases of recurrent sweating after surgical treatment?
Although it exists in the literature, I have never encountered it until today.
11. Apart from surgery, what are the other methods used to control excessive sweating?
There are drug treatments such as topical aluminum chloride (axillary agents), oral anticholinergics, benzodiazepines, calcium channel blockers.
Others are tap water or anticholinergic iontopharyngeal methods, which are difficult to apply, and Botox applications, which are temporary treatments. Liposuction of the underarm adipose tissue can also be used for underarm sweating.
12. Do age, gender or other factors have an impact on the treatment of excessive sweating?
There is no good.
13. What should patients consider before agreeing to surgical treatment?
In question 8, it is enough to know that you have taken the two important risks I mentioned.
14. What are the lifestyle changes that should be made after surgical treatment?
No changes are required.
15. What are the latest developments and research in the treatment of excessive sweating?
I have not yet come across a specific article that specifies a method other than what I have described.