The Treatment of Axillary Odor: A Network Meta-Analysis.

BACKGROUND Axillary osmidrosis (AO) is common in plastic surgery. But there is no perfect way to treat AO. We systematically compared the efficacy of 10 AO treatments with network meta-analysis in order to provide reference for the clinical treatment of axillary odor. MATERIAL AND METHODS Chinese and English databases were searched by computer. Some relevant studies were collected for network meta-analysis. RESULTS We identified 56 studies, including a total of 8618 patients for meta-analysis. The network meta-analysis showed that 21 out of 45 pairs of 10 AO treatments had no statistical significance. In statistical comparison, subcutaneous curettage and swelling suction subcutaneous pruning were better than a single treatment. In addition, the effects of both laser and electric ion therapy were inferior to those of other treatments. The order of therapeutic effects predicted by surface under the cumulative ranking (SUCRA), curve was swelling aspiration+subcutaneous pruning >subcutaneous pruning >subcutaneous curettage+subcutaneous pruning >spindle excision >botulinum toxin A injection >swelling aspiration >subcutaneous curettage >YAG laser therapy >CO2 laser therapy >electric ion therapy. CONCLUSIONS In operative treatment of AO, swelling aspiration+subcutaneous pruning is the best operative treatment, and botulinum toxin A injection is the best in non-operative treatment. Overall, the effect of surgical treatment was more significant than that of non-surgical treatment.

Effectiveness of bilateral clipping of the thoracic sympathetic chain for the treatment of severe palmar and/or axillary hyperhidrosis and facial flushing. / Efectividad de la interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip para el tratamiento de la hiperhidrosis palmar y/o axilar severa y el rubor facial.

INTRODUCTION: Division of the thoracic sympathetic chain is the standard treatment for severe palmar and/or axillary hyperhidrosis and facial flushing. Clipping is an alternative option which allows the block to be reverted in cases of intolerable compensatory sweating. METHODS: This is a prospective study performed to assess: a) results of clipping of the thoracic sympathetic chain in patients with palmar and/or axillary hyperhidrosis and facial flushing; and b) to determine the improvement obtained after removal of the clip in patients with unbearable compensatory sweating. We included 299 patients (598 procedures) diagnosed with palmar hyperhidrosis (n=110), palmar and/or axillary hyperhidrosis (n=78), axillary hyperhidrosis (n=35), and facial flushing (n=76), who underwent videothoracoscopic clipping between 2007 and 2015. RESULTS: 128 men and 171 women were treated, with mean age of 28 years. A total of 290 patients (97.0%) were discharged within 24hours. The procedure was effective in 92.3% (99.1% in palmar hyperhidrosis, 96,1% in palmar and/or axillary hyperhidrosis, 74.3% in axillary hyperhidrosis, and 86.8% in facial flushing). Nine patients (3%) presented minor complications. Compensatory sweating developed in 137 patients (45.8%): moderate in 113 (37.8%), severe in 16 (5.3%) and unbearable in 8 (2.7%). The clip was removed in these 8 patients; symptoms improved in 5 (62.8%), with sustained effect on hyperhidrosis in 4 of them. CONCLUSIONS: Clipping of the thoracic sympathetic chain is an effective and safe procedure. If incapacitating compensatory sweating develops, this technique allows the clips to be removed with reversion of symptoms in a considerable number of patients.

Neural control of sweat secretion: a review.

BACKGROUND: Humans have 4 million exocrine sweat glands, which can be classified into two types: eccrine and apocrine glands. Sweat secretion, a constitutive feature, is directly involved in thermoregulation and metabolism, and is regulated by both the central nervous system (CNS) and autonomic nervous system (ANS). OBJECTIVES: To explore how sweat secretion is controlled by both the CNS and the ANS and the mechanisms behind the neural control of sweat secretion. METHODS: We conducted a literature search on PubMed for reports in English from 1 January 1950 to 31 December 2016. RESULTS AND CONCLUSIONS: Acetylcholine acts as a potent stimulator for sweat secretion, which is released by sympathetic nerves. ß-adrenoceptors are found in adipocytes as well as apocrine glands, and these receptors may mediate lipid secretion from apocrine glands for sweat secretion. The activation of ß-adrenoceptors could increase sweat secretion through opening of Ca2+ channels to elevate intracellular Ca2+ concentration. Ca2+ and cyclic adenosine monophosphate play a part in the secretion of lipids and proteins from apocrine glands for sweat secretion. The translocation of aquaporin 5 plays an important role in sweat secretion from eccrine glands. Dysfunction of the ANS, especially the sympathetic nervous system, may cause sweating disorders, such as hypohidrosis and hyperhidrosis.

Old and New Approaches for Assessing Sweating.

The evaluation of sweating activities contributes to both medical services and social living. There are several old and new approaches for assessing sweating. These methods are mainly composed of adopted techniques that focus on detecting small amounts of water on the skin surface. For many years, the iodine-starch reaction has been applied in various settings to evaluate sweat on the skin surface. However, methodology based on the coloration of sweat is in a constant state of evolution, and multiple advancements have been made. Furthermore, common fingerprinting is not just used for obtaining personal-identifying information anymore as it can also provide scientifically important information for sweat-pore mapping and sweat-component analysis. Additionally, there are multiple techniques for the quantitative measurement of sweat volume and dynamic intravital imaging of sweat, and these are also continually evolving. This chapter provides an overview of the old and new approaches for assessing sweating.

Genetic Disorders with Dyshidrosis: Ectodermal Dysplasia, Incontinentia Pigmenti, Fabry Disease, and Congenital Insensitivity to Pain with Anhidrosis.

Sweating is regulated by various neurohormonal mechanisms. A disorder in any part of the sweating regulatory pathways, such as the thermal center, neurotransmitters in the central to peripheral nerve, innervation of periglandular neurotransmission, and sweat secretion in the sweat gland itself, induces dyshidrosis. Therefore, hereditary disorders with dyshidrosis result from a variety of causes. These diseases have characteristic symptoms derived from each pathogenesis besides dyshidrosis. The information in this chapter is useful for the differential diagnosis of representative genetic disorders with dyshidrosis.

Sweating in Systemic Abnormalities: Uremia and Diabetes Mellitus.

Sweating disorders are sometimes observed in various systemic diseases that include genetic disorders, organ damage, metabolic impairment, autoimmune diseases, and neuropathic disorders. In these diseases, various symptoms such as autonomic failures, psychopathic disorders, abnormal skin innervation, and sweat gland dysfunction can interact with one another in diverse ways, resulting in impaired sweating. This review focuses on the influence of uremia (with or without hemodialysis) and diabetes mellitus on impaired sweating. Dialysis patients perspire less, but their sweat contains higher levels of uremic toxins than do healthy subjects. Neuropathic disorders in diabetes patients develop in relation to disease severity and can impair sweating. Physicians should consider the development of various problems, such as increased body temperature, dry skin, and increased susceptibility to infection, due to decreased sweating, as they are often found in these systemic abnormalities.

Sympathetic cardiovascular and sudomotor functions are frequently affected in early multiple sclerosis.

OBJECTIVE: The aim of this study was to determine the prevalence of autonomic dysfunction using the composite autonomic scoring scale (CASS) and heart rate variability (HRV) in patients with clinically isolated syndrome (CIS) and to correlate autonomic dysfunction with other measures of MS disease activity. METHODS: CASS, HRV and plasma catecholamines during supine and tilted phase were performed in 104 CIS patients. MRI findings were analyzed for total number of lesions and the presence of brainstem and cervical spinal cord lesions. RESULTS: Autonomic dysfunction (CASS >1) was present in 59.8 % of patients, parasympathetic dysfunction in 5 %, sympathetic in 42.6 % and sudomotor in 32.7 % of patients. Patients with autonomic dysfunction on CASS had lower level of norepinephrine in the supine position compared to patients without autonomic dysfunction (1.06 ± 0.53 vs. 1.37 ± 0.86, p = 0.048). The CASS score showed positive correlation with s-HF (r = 0.226, p = 0.031), s-SDNN (r = 0.221, p = 0.035), t-HF (r = 0.225, p = 0.032), and t-HFnu (r = 0.216, p = 0.04), and a negative correlation with t-LF/HF (r = -0.218, p = 0.038). More patients with MRI brainstem lesions had a positive adrenergic index (p = 0.038). Patients with MRI brainstem lesions also had a lower t-SDNN (26.2 ± 14.2 vs. 32 ± 13.3, p = 0.036) and a lower t-LF (median 415.0 vs. 575.5, p = 0.018) compared to patients without these lesions. Patients with adrenergic index ≥1 had a significantly higher standing heart rate compared to patients with an adrenergic index of 0 (96 ± 13.5 vs. 90 ± 12, p = 0.032). CONCLUSION: Autonomic (primarily sympathetic) dysfunction is present in a large proportion of early MS patients and it seems to be related to brainstem involvement.

Sweating on the palm and sole: physiological and clinical relevance.

In mammals, sweating is a multifunctional response that aids in locomotion, thermal regulation, self-protection, and communication of psychological state. Humans possess three types of sweat glands (apocrine, eccrine, and apoeccrine) that are differentially distributed on the body surface and make unique contributions to these distinct functions of the sweating response. In humans, eccrine glands, which are widely distributed on hairy skin, play an important role in thermoregulation. They are also found on the glabrous skin of the palm and sole, where they are not usually activated by heat, but rather by deep respiration, mental stress, and local tactile stimulation. Sweating on the palm and sole, so-called "emotional sweating", acts to prevent slippage while grasping or performing a delicate task using the fingertips. Although the central pathways of emotional sweating are not yet elucidated in detail, it is thought that the amygdala, cingulate cortex, and medulla participate via efferent fibers that descend through the spinal cord and connect to preganglionic sympathetic neurons in the nucleus intermediolateralis. The limbic system, including the amygdala and cingulate cortex, is critical for emotional processing and many cognitive functions. Thus, measurement of sweat output on the palm or sole is useful for evaluating sympathetic function and limbic activity in autonomic and psychiatric disorders.

Treatment of axillary osmidrosis using a laser with a 1,444-nm wavelength.

BACKGROUND: Lasers have been proposed as an alternative treatment for axillary osmidrosis. OBJECTIVE: This study aimed to investigate the use of a neodymium:yttrium-aluminum-garnet laser with a wavelength of 1,444 nm for treating axillary osmidrosis. MATERIALS AND METHODS: Eighteen patients with axillary osmidrosis who underwent an operation with a 1,444-nm wavelength laser were included in this study. Operative parameters were as follows: pulse = 40 Hz and energy = 170 mJ. Total energy was approximately 2,000 to 3,400 J, and the operation time was 45 minutes. RESULTS: Statistically significant differences in the degree of malodor evaluated by both the patients (p = .001) and doctors (p = .012) were detected between preoperative and 6-month postoperative assessments. Sweat area was significantly reduced 6 months after the operation compared with preoperative values. Postoperative pain had subsided at day 7 in all but 1 patient. Two patients (11.1%) experienced superficial second-degree burns on the unilateral axilla; these burns were resolved fully. CONCLUSION: The laser with a wavelength of 1,444 nm was found to be a reliable method for the treatment of axillary osmidrosis, with advantages such as small wound size, rapidity of the procedure, inconspicuous scars, and speedy recovery and return to normal daily activities.

Sweat gland progenitors in development, homeostasis, and wound repair.

The human body is covered with several million sweat glands. These tiny coiled tubular skin appendages produce the sweat that is our primary source of cooling and hydration of the skin. Numerous studies have been published on their morphology and physiology. Until recently, however, little was known about how glandular skin maintains homeostasis and repairs itself after tissue injury. Here, we provide a brief overview of sweat gland biology, including newly identified reservoirs of stem cells in glandular skin and their activation in response to different types of injuries. Finally, we discuss how the genetics and biology of glandular skin has advanced our knowledge of human disorders associated with altered sweat gland activity.

Muscle and skin sympathetic activities in Ross syndrome.

OBJECTIVES: Ross syndrome (RS) is a rare degenerative disorder characterized by tonic pupil, areflexia and anhydrosis. The underlying lesion affects postganglionic skin sympathetic nerve fibers whereas the postganglionic muscle sympathetic branch is thought to be spared. Microneurography explores both skin and muscle peripheral sympathetic branches and it does not usually detect peripheral sympathetic outflow in either branch in chronic autonomic failure syndromes. The aim of this study was to record sympathetic activity by microneurography for the first time in RS patients to confirm the selective involvement of skin sympathetic nerve activity (SSNA) with spared muscle sympathetic nerve activity (MSNA). METHODS: We studied seven patients (49 ± 14 years, four males) with a typical clinical picture and skin biopsy findings. Patients underwent cardiovascular reflexes and microneurography from the peroneal nerve (anhydrotic skin) to record MSNA, SSNA and the corresponding organ effector responses (skin sympathetic response-SSR and skin vasomotor response-SVR) in the same innervation field. The absence of sympathetic bursts was established after exploring at least three different corresponding nerve fascicles. Twenty age-matched healthy subjects served as controls. RESULTS: RS patients complained of diffuse anhydrosis and they showed tonic pupil and areflexia. Cardiovascular reflexes were normal. All patients displayed absent SSNA, SSR and SVR whereas MSNA was always recorded showing normal characteristics. CONCLUSION: Microneurographic study of sympathetic activity from affected skin confirmed the selective involvement of skin sympathetic activity with spared muscle sympathetic activity and it may represent the neurophysiological hallmark of the disease. SIGNIFICANCE: Microneurography together with clinical and skin biopsy findings may contribute to RS diagnosis. Our data also suggest that autonomic damage in RS does not involve cardiovascular activity.

Sudomotor dysfunction in autoimmune autonomic ganglionopathy: a follow-up study.

OBJECTIVE: We have previously shown that sudomotor dysfunction in autoimmune autonomic ganglionopathy is severe, widespread, and predominantly post-ganglionic. However, the long-term changes in sudomotor function have not been studied in detail. Our objective was to characterize the long-term changes in sudomotor dysfunction in patients with autoimmune autonomic ganglionopathy. METHODS: Changes in sudomotor function were compared in a cohort of nine α3 nAChR antibody positive autoimmune autonomic ganglionopathy patients over an approximate 5-year period. Standard measurements of sudomotor function were used including the thermoregulatory sweat test and quantitative sudomotor axon reflex test. RESULTS: Total body anhidrosis on thermoregulatory sweat testing showed improvement in four of nine patients. Quantitative sudomotor axon reflex testing for both forearm and foot sites was variable with four of nine patients showing improvement in total sweat output. Distribution of sudomotor dysfunction at follow-up was post-ganglionic in seven of nine patients at the foot site and three of nine patients at the forearm site. Overall, sudomotor dysfunction was post-ganglionic in seven of nine patients throughout the follow-up period (62.4 ± 19.4 months). INTERPRETATION: Sudomotor dysfunction in autoimmune autonomic ganglionopathy was severe and widespread throughout the follow-up period for the majority of patients studied. Sudomotor dysfunction was predominantly post-ganglionic throughout the follow-up period.

Excision of apocrine glands and axillary superficial fascia as a single entity for the treatment of axillary bromhidrosis.

BACKGROUND: Surgical excision of apocrine glands is the effective treatment for axillary bromhidrosis. Skin necrosis, the most serious adverse result observed postoperatively, results in a prolonged wound healing and leads to unsightly scars in the axillary fossae. It is mainly caused by the skin damage during the operation and postoperative seroma or haematoma formation. OBJECTIVE: To investigate the effects and complications of our surgical modality for axillary bromhidrosis. METHODS: Sixty-three patients with bromhidrosis were treated. An incision about two-thirds of the length of the widest transverse diameter was made on the axillary crease. The loosened layers between the dermis and axillary superficial fascia containing apocrine glands were carefully undermined with an iris scissor. The entire apocrine glands-axillary superficial fascia complex was dissected from the centre to the superior and inferior margins with an electrosurgical pencil. RESULTS: Of the 126 axillae, malodour was eradicated in 112 axillae and reduced sharply in 14. There were three cases of skin necroses. The Dermatology Life Quality Index score decreased significantly and the quality of life improved after the operation. CONCLUSION: Our surgical technique can achieve minimal tissue damage and maintain no hematoma postoperatively. The rate of skin necrosis was low. Quality of life improved after the procedure in this patient population.

Axillary chromhidrosis: report of a case, review of the literature and treatment considerations.

Chromhidrosis is a rare but troubling syndrome whose cardinal feature is the appearance of colored sweat. In some instances, this may be associated with the use of drugs or ingested materials [Dermatology vol. 199 (1999) 149-52] but in others it is idiopathic. Irrespective of the etiology, the appearance of colored sweat can be profoundly psychologically disturbing. We report the case of a woman who had been affected by chromhidrosis for several years. Treatment with botulinum toxin type A resulted in a cessation of the problem with profoundly improved quality of life for this individual. This is significant because it is the first case of isolated axillary chromhidrosis treated with botulinum toxin A and, as with reports of facial chromhidrosis [Journal of the American Academy of Dermatology vol. 52 (2005) 89-91], resolution of the symptoms supports the eccrine etiology of this entity.

A new simple method for assessing sudomotor function: relevance in type 2 diabetes.

AIM: The current sudomotor function tests are too time-consuming to be used for diabetic patients in daily practice. EZSCAN is a new, patented technology that measures electrochemical skin conductance (ESC) through reverse iontophoresis and chronoamperometry. The aim of the present study was to assess the sensitivity, specificity and reproducibility of the method in type 2 diabetic patients in comparison to control subjects with no risk of diabetes. METHODS: A total of 133 type 2 diabetic patients and 41 control subjects were tested. Participants placed their hands and feet on nickel electrodes, and an incremental low direct current was applied to the anode for 2 min. ESC was calculated from the resulting voltage and generated current. ESC diagnostic accuracy was analyzed by ROC curve modeling, and reproducibility was assessed using Bland-Altman analysis. RESULTS: The ESC of hands and feet was significantly reduced in diabetic patients (53±16µSi and 67±14µSi, respectively) compared with control subjects (68±16µSi and 80±7µSi, respectively; P<0.0001). ESC values had a sensitivity of 75% and specificity of 100%, with an area under the ROC curve of 0.88 at a threshold of 50% on the EZSCAN scale. Coefficients of variation in hand and foot measurements were 15 and 7%, respectively. CONCLUSION: The good sensitivity, specificity and reproducibility of EZSCAN make it a feasible alternative for assessing sudomotor dysfunction, a clinical manifestation of autonomic neuropathy in diabetic patients. The test takes<3 min to perform, and requires neither special patient preparation nor medical personnel training.

[Case of Parkinson disease with heat retention due to sweating dysfunction].

A 71-year-old man was diagnosed as Parkinson disease at age 59, and levodopa therapy was started. Eleven years after the beginning of treatment, he noticed high fever (38.0 degrees C-39.0 degrees C) in July, but hyperthermia spontaneously disappeared three months later. In early July of the following year, he was re-admitted to our hospital because of continuous high fever, despite no any inflammation. Neurological examination revealed flexion posture of trunk and limbs and short step gait. He also presented limb rigidity, akinesia, and resting tremor during off period. Routine laboratory examinations and radiological examinations showed no remarkable findings. Autonomic testing revealed orthostatic hypotension and anhidrosis below trunk and lower limbs. By controlling the room temperature at 26 degrees C, hyperthermia showed a marked decline. In despite of no reports found associations between heat retention and Parkinson disease, in this case we speculate hyperthermia was caused by heat retention.

Sudomotor, skin vasomotor, and cardiovascular reflexes in 3 clinical forms of Lewy body disease.

OBJECTIVE: To elucidate the differences among dementia with Lewy bodies (DLB), Parkinson disease with dementia (PDD), and Parkinson disease without dementia (PD), with respect to the involvement of the autonomic nervous system, we clinically investigated the cutaneous and cardiovascular autonomic functions in patients with Lewy body disease. METHODS: We studied 36 patients with Lewy body disorders, including 12 patients with DLB (age, 75.4 +/- 5.9 years), 12 patients with PDD (71.0 +/- 6.8 years), and 12 patients with PD (70.9 +/- 4.2 years), and 12 healthy control subjects (69.9 +/- 5.3 years). Sympathetic sweat response (SSwR) and skin vasomotor reflex (SkVR) on the palm were recorded to estimate the cutaneous sympathetic function, and the head-up tilt test was performed and coefficient of variation of R-R intervals (CV(R-R)) was studied to estimate the cardiovascular function. RESULTS: The patients with DLB, patients with PDD, and patients with PD showed severely reduced SSwR amplitudes, significantly lower than that in the controls. The mean SkVR amplitudes in the patients with DLB and patients with PDD were significantly lower than that in the controls, but not in the patients with PD. The mean decreases in the systolic blood pressure during the head-up tilt test in the patients with DLB and patients with PDD were less than that in the controls. The mean CV(R-R) value was significantly lower in the patients with DLB. CONCLUSION: Sudomotor function on the palm may be severely affected in Lewy body disorders, while skin vasomotor function and the cardiovascular system may be more severely affected in dementia with Lewy bodies and Parkinson disease with dementia than in Parkinson disease.

Prospective differentiation of multiple system atrophy from Parkinson disease, with and without autonomic failure.

OBJECTIVE: To report preliminary results of a prospective ongoing study of multiple system atrophy (MSA) and Parkinson disease (PD), with a large subset of patients with PD with autonomic failure (25%), to evaluate autonomic indices that distinguish MSA from PD. METHODS: We used consensus criteria, detailed autonomic studies (Composite Autonomic Symptom Scale, Composite Autonomic Scoring Scale, thermoregulatory sweat test, and plasma catecholamines), and functional scales (Unified MSA Rating Scale [UMSARS] I-IV and Hoehn-Yahr grading) on a prospective, repeated, and ongoing basis. RESULTS: We report the results of a study on 52 patients with MSA (mean [SD], age, 61.1 [7.8] years; body mass index (calculated as weight in kilograms divided by height in meters squared), 27.2 [4.6]; Hoehn-Yahr grade, 3.2 [0.9]; UMSARS I score, 21.5 [7.4]; and UMSARS II score, 22.7 [9.0]) and 29 patients with PD, including PD with autonomic failure (mean [SD], age, 66.0 [8.1] years; body mass index, 26.6 [5.5]; Hoehn-Yahr grade, 2.2 [0.8]; UMSARS I score, 10.4 [6.1]; and UMSARS II score, 13.0 [5.9]). Autonomic indices were highly significantly more abnormal in MSA than PD (P < .001) for the Composite Autonomic Scoring Scale (5.9 [1.9] vs 3.3 [2.3], respectively), Composite Autonomic Symptom Scale (54.4 [21.8] vs 24.7 [20.5], respectively), and thermoregulatory sweat test (percentage anhidrosis, 57.4% [35.2%] vs 9.9% [17.7%], respectively). These differences were sustained and greater at 1-year follow-up, indicating a greater rate of progression of dysautonomia in MSA than PD. CONCLUSIONS: The severity, distribution, and pattern of autonomic deficits at study entry will distinguish MSA from PD, and MSA from PD with autonomic failure. These differences continue and are increased at follow-up. Our ongoing conclusion is that autonomic function tests can separate MSA from PD. Autonomic indices support the notion that the primary lesion in PD is ganglionic and postganglionic, while MSA is preganglionic.