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Profuse Facial Sweating: Your Approach for this Case Discussion?
by Dr. Christer Drott
A 45 year old high school teacher of music seeks your advice for profuse facial sweating. He is previously healthy without any regular medication. The sweating has gradually increased during the years. He is now quite incapacitated as sweat is pouring down his face regardless of environmental temperature. This is especially triggered by being in the centre of attention which he often is. To bring in additional income he works as guitar player at parties and funerals. The extensive sweating has led to severe reluctance to perform in public. Endocrinologic investigations have shown normal results. He has tried anticholinergic drugs, betareceptor blockers and sedatives with no effect, only side-effects. He is now quite desperate as he has had several sickleaves and cancellations of extra performances leading to a strained economy and marriage. What is your recommendation for treatment?
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November 18th, 2008 at 9:29 pm
In such case if testosterone problems (male climax) is excluded by trial treatment I would recommend first to try botox as much as possible - forehead, nose, and everywhere carefully to avoid oral and ocular disfunctions - botox has minimal diffusion so mnimal doses per injection with many injections has good chance to avoid muscle problems. Other brands (disport or lantox) diffuse better and I usually avoid them.
If it does not work I would recommend 1 clip above T2 with risk of severe trunk hyperhidrosis.
November 19th, 2008 at 10:11 am
Dr. Drott
I have review the patient information and this is a difficult problem. Currently, I do not opperate on these patients based on my lack of experience with this problem and my review of the data in the literature. Most papers on craniofacial hyperhidrosis report resonable results (70-90%) success with T2 procedures in carefully selected patients… however most also describe 80-90% compensatory hyperhidrosis (severe 5-20%) with 5-20% of patients regretting the surgery. Perhaps as more data is available then I may change my approach. I would encourage you to review Chest Surgery Clinics of North America (May 2008, Vol 18, Number 2) on Hyperhidrosis (page 184-186) for a review on the topic.
I seem to recall a recent paper by Dr. Dan Miller (annals of thoracic surgery or JCTVS) where he would do VATS with injection of local anesthetic near the trunk to see if the patient improved without severe side effects prior to a more definitive procedure…might be an option. Good Luck.
November 19th, 2008 at 11:56 am
I agree with the above plan to use Botox in as many areas as possible without injecting it into areas that are critical to muscular function. You might have to inject as much as 50-100 units in scattered areas of the face, avoiding brow elevators and lip elevators and depressors. It should last as long as 6 months.
November 19th, 2008 at 8:16 pm
I used to operate on patients with cranio-facial hypepr hidrosis. For the last 8-9 years I stopped performing ETS fot that indication. Not only that the results are not as good as for the hands but also those patients have more severe cases of compensatory sweating. Because of the neccessity to stay high on T-2 the patients are getting more cases of severe gustatory sweating,more complaints of mental issues such as being tired and loss of concentration.Following a large number of unhappy patients from variuos sources the great majority were done for indications other than palmar hyperhidrosis.
I`ll try this patient with any conservative measure available. The fact that the patient has a problem does not mean that we have to offer him with an operation that will work only partially,temporarily and leave him with side effects wors that his initial problem.
Rafael Reisfeld M.D.