内分泌 異常発汗

更年期は　夜間の発汗 特発性多汗症は　夜間はない ＝＝＝＝＝＝＝＝＝＝＝＝ ①　Dynamed ②　HP ３　漢方 ＿＿＿＿＿＿＿＿＿＿ 防已黄耆湯（ぼういおうぎとう） 多汗症の漢方（漢方薬）治療において一番ポピュラーな漢方薬です。特に、気温の高さに比例して汗の量が増える人、やや太り気味の人に効果がみられます。 桂枝加黄耆湯（けいしかおうぎとう） 発汗のバランスを整えて、全身性の発汗を抑える効果があります。虚弱体質な人向けの漢方薬になります。 柴胡桂枝乾姜湯 （さいこけいしかんきょうとう） 顔や手、わきの下など上半身の多汗症に効果がある漢方薬です。こちらも虚弱体質で疲れやすい人に適しています。 ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿ Description: excessive sweating(2) may be focal or generalized may or may not have apparent underlying cause focal hyperhidrosis more often idiopathic Also called: excessive sweating gustatory sweating also called Frey's syndrome Baillarger's syndrome Frey-Baillarger syndrome Dupuy's syndrome auriculotemporal syndrome ICD-9 Codes: 705.2 focal hyperhidrosis 705.21 primary focal hyperhidrosis 705.22 secondary focal hyperhidrosis 780.8 generalized hyperhidrosis ICD-10 Codes: R61 hyperhidrosis R61.0 localized hyperhidrosis R61.1 generalized hyperhidrosis R61.9 hyperhidrosis, unspecified Types: focal hyperhidrosis(2, 3) also called primary, idiopathic, or essential hyperhidrosis usually affects discrete sites (palms, soles, axillae, craniofacial) usually due to overactivity of sudomotor system with no obvious cause types of focal hyperhidrosis include palmar-plantar hyperhidrosis - excess sweating of palms of hands and soles of feet isolated axillary hyperhidrosis - excess sweating of underarms craniofacial hyperhidrosis - isolated excess sweating of face gustatory hyperhidrosis - excess sweating of face, triggered by spicy foods generalized hyperhidrosis(2) also called secondary hyperhidrosis may have any of several underlying causes Organs Involved: skin, autonomic nervous system(3) Who is most affected: males and females equally affected(1) focal hyperhidrosis typically has onset at puberty(1) severe palmar hyperhidrosis more common in Southeast Asia(2) Incidence/Prevalence: 2.9% prevalence of hyperhidrosis in mailed survey of 150,000 United States households, 1.4% have axillary hyperhidrosis (J Am Acad Dermatol 2004 Aug;51(2):241) estimated 0.6-1% incidence in adolescents and young adults in Israel, based on unreferenced "pilot epidemiological study" (Ann Surg 1977 Jul;186(1):34 PDF) Causes and Risk Factors Causes: focal hyperhidrosis usually idiopathic, but may be responsive to emotional stimuli(2) compensatory hyperhidrosis on one part of body following absence of sweating on another part following(1) injury to sympathetic trunk diabetic neuropathy thoracic sympathectomy generalized hyperhidrosis (secondary) neurological diseases(2) diencephalic epilepsy autonomic dysreflexia orthostatic hypotension spinal cord injury post-traumatic syringomyelia malignancies(2) leukemia Hodgkin's disease(1) renal adenocarcinoma Castleman disease mesothelioma(1) carcinoid tumor(1) endocrine conditions(2) acromegaly diabetes mellitus pheochromocytoma hyperthyroidism hypothalmic lesions(1) chronic infection(2) tuberculosis brucellosis cardiovascular disease(1) heart failure myocardial ischemia respiratory failure(1) drug adverse effect antidepressants about 14% of patients taking venlafaxine (Effexor XR) about 6% of patients taking bupropion (Wellbutrin XL or SR) also occurs with Selective Serotonin Reuptake Inhibitors (SSRIs), tricyclic antidepressants, duloxetine (Cymbalta) opiates, especially fentanyl, methadone, oxycodone clozapine (about 6% of patients) cholinergic agents such as pilocarpine fludarabine nicotine nitrates, nitroprusside propafenone Reference - Prescriber's Letter 2006 Jul;13(7):38 insulin(1) aspirin(1) acetaminophen(1) anti-emetics(1) Pathogenesis: excessive sweating in response to sensation or emotion reflects activity in anterior cingulate frontal cortex(2) mental stress may stimulate sympathetic nerve activation and vasoconstriction in skin, and excess sweating(2) hyperhidrosis not associated with histopathologic changes in sweat glands or numbers of sweat glands(3) Likely risk factors: family history hyperhidrosis can be inherited as symptom of(2) familial dysautonomia (autosomal recessive) nail-patella syndrome (autosomal dominant) primary palmar hyperhidrosis appears hereditary with variable penetrance 49 patients with palmar, plantar, or axillary hyperhidrosis and 20 controls were interviewed for family history 65% of hyperhidrosis group vs. 0% in control group reported positive family history Reference - J Vasc Surg 2002 Feb;35(2):382 Possible risk factors: mental or emotional stress(2) Complications and Associated Conditions Complications: maceration of skin increases risk of bacterial and/or fungal infection(1) pompholyx, type of eczema causing blisters on palms and/or soles (Contact Dermatitis 1992 Jan;26(1):17) contact dermatitis(1) social embarrassment(2,3) may interfere with intimacy, activities of daily living, participation in sports, and employment Social phobia Associated conditions: chromhidrosis (darkened facial skin)(2) bromhidrosis (foul-smelling sweat)(2) History Chief Concern (CC): excessive sweating History of Present Illness (HPI): ask about age of onset(2) pattern of sweating - location, duration, frequency, symmetry, timing, triggers(4)) need to change clothing frequently(2) impact on activities of daily living and quality of life(1,4) Medication History: consider medication history for potential Causes Family History (FH): 25-50% of patients with focal hyperhidrosis have family history(2, 4) Social History (SH): embarrassment(2) up to one third of patients with social anxiety disorder may experience hyperhidrosis, and it may be associated with higher levels of disability, fear, avoidance, and other physiologic symptoms (Prog Neuropsychopharmacol Biol Psychiatry 2002 Dec;26(7-8):1327) Review of Systems (ROS): especially consider nervous and endocrine systems(2) Physical General Physical: underlying causes of focal hyperhidrosis may present signs and symptoms (J Am Acad Dermatol 2004 Aug;51(2):274) Skin: look for evidence of excess sweating, especially in characteristic regions(1) axillae palms of hands soles of feet craniofacial area maceration(2) pigmentation(2) Diagnosis Making the diagnosis: diagnostic criteria for primary focal hyperhidrosis focal, visible, excessive sweating for at least 6 months without underlying cause affecting axillae, palms, soles, or craniofacial region plus at least 2 of the following symmetry (bilateral presentation) impairment of activities of daily living events occur more than once a week age of onset < 25 years positive family history excessive sweating does not occur during sleep Reference - J Am Acad Dermatol 2004 Aug;51(2):241 generalized hyperhidrosis usually part of some underlying condition(4) Rule out: normal sweating Testing to consider: in cases of focal hyperhidrosis(3, 4) does not require laboratory tests if characteristic presentation starch iodine test can outline area of excessive sweating tests that may be useful to identify primary cause of generalized hyperhidrosis(1) complete blood count (CBC) erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) blood urea nitrogen (BUN) electrolytes glucose thyroid function chest x-ray blood film for malaria parasites if clinical suspicion HIV test if clinical suspicion Other diagnostic testing: Minor’s starch-iodine test to delineate affected area(2) iodine solution 3.5% in alcohol is applied to clean, dry shaved skin dry starch powder is applied lightly and sweat turns mixture dark blue gravimetric analysis or dynamic sudorometry to determine rate of sweat production(2) in gravimetric analysis a filter paper is placed over defined area of sweating for 60 seconds and amount of sweat collected determined gravimetrically by subtracting the filter pre-test weight from the post-test weight, rate of sweat production is quantified as milligrams/minute/cm in quantitative sudorometry local sudomotor axon reflex sweating is induced by transcutaneous iontophoresis (1 mA, 5 minutes) of 1% carbachol and the sweat output measured by capacitance hygrometry over a defined skin area thermoregulatory sweat test(2) mixture of alizarin red, cornstarch and sodium carbonate is applied to skin of whole body focal hyperhidrosis areas delineated and photographed patient then exposed to heat change in tented heat cabinet and skin and oral temperatures and thermoregulatory sweat recruitment patterns are recorded oral temperature is raised to 38 degrees C, the sweating temperature for healthy patients, turning the skin applied mixture dark purple outside the cabinet the patient is photographed and a computer drawing derived, and from measurements of the different colored areas of the body the percentage of anhidrosis and hyperhidrosis areas calculated Prognosis Prognosis: chronic, with occasional spontaneous remission(1) effective treatment can improve quality of life(4) Treatment Treatment overview: sweat reduction and concealment axillary hyperhidrosis 20% aluminum chloride hexahydrate (high-strength antiperspirant) may be effective in most cases of mild axillary hyperhidrosis (level 2 [mid-level] evidence) botulinum toxin type A (Botox) intradermal injections effective for up to 16 weeks and for improving quality of life (level 1 [likely reliable] evidence) topical botulinum toxin type A may be associated with reduction in sweating for patients with axillary hyperhidrosis (level 2 [mid-level] evidence) endoscopic thoracic sympathetic block may improve quality of life in upper limb hyperhidrosis (level 2 [mid-level] evidence) sympathectomy at T4 level or T3-T4 level appears equally effective for axillary hyperhidrosis, but T4 level associated with less compensatory hyperhidrosis (level 2 [mid-level] evidence) palmar hyperhidrosis topical 20% aluminum chloride hexahydrate appears effective for reducing palmar hyperhidrosis (level 2 [mid-level] evidence) botulinum toxin A appears to reduce palmar hyperhidrosis (level 2 [mid-level] evidence) botulinum toxin type B (Myobloc) injection may be associated with improved quality of life (level 2 [mid-level] evidence) endoscopic thoracic sympathetic block may improve quality of life in upper limb hyperhidrosis (level 2 [mid-level] evidence) level of sympathectomy may affect incidence of compensatory hyperhidrosis (level 2 [mid-level] evidence) tap water iontophoresis might reduce area of focal hyperhidrosis (level 2 [mid-level] evidence) glycopyrrolate iontophoresis might have longer treatment effect than tap water iontophoresis (level 2 [mid-level] evidence) iontophoresis with botulinum toxin type A may reduce sweating in patients with primary palmar hyperhidrosis (level 2 [mid-level] evidence) facial hyperhidrosis glycopyrrolate 0.5% topical cream may reduce diabetic gustatory sweating (level 2 [mid-level] evidence) gustatory sweating may be reduced by botulinum toxin type A intracutaneous injection (level 2 [mid-level] evidence) clonidine 0.6-1.2 mg/day in 2-3 divided doses reported as consideration for craniofacial or gustatory hyperhidrosis (level 3 [lacking direct] evidence) systemic treatments generally not recommended (grade C recommendation [lacking direct evidence]) Activity: sweat reduction and concealment(1) dress to dissipate heat easily wear clothes that do not easily show sweat marks use antiperspirant use absorbent dusting powder (talc) wear garments with loose fit around armpits Medications: Topical agents: aluminum salts common ingredient of over-the-counter antiperspirants(2, 4) most commercial antiperspirants contain 1-2% aluminum salts, but 20-25% aluminum chloride concentrations are available high concentration solutions must be applied to dry skin at bedtime and washed off 6-8 hours later aluminum chloride FDA approved for topical use in treatment of hyperhidrosis 12% aluminum chloride as stick (Certain Dri) available over-the-counter for axillary hyperhidrosis aluminum chloride hexahydrate available as topical solutions 6.25% solution as Xerac AC 20% solution as Drysol or as Hypercare see aluminum chloride (topical) for details 20% aluminum chloride hexahydrate appears effective for reducing palmar hyperhidrosis (level 2 [mid-level] evidence) based on small within-patient comparison trial 12 men aged 19-37 years with symptomatic idiopathic palmar hyperhidrosis were treated with aluminum chloride hexahydrate on one palm nightly for 4 weeks vs. no treatment on other palm treatment reduced skin water vapor loss with borderline statistical significance all patients reported treated palms were drier than untreated palms the morning after starting treatment, but effect disappeared within 2 days after treatment stopped Reference - Int J Dermatol 1990 Jun;29(5):368 20% aluminum chloride hexahydrate may be effective in most cases of mild axillary hyperhidrosis (level 2 [mid-level] evidence) based on uncontrolled prospective study with very high response rate 65 patients with axillary hyperhidrosis were treated with 20% aluminum chloride hexahydrate topically each night for 1 week, then as needed most patients applied solution once every 7-21 days after initial treatment 64 of 65 patients reported complete control of axillary sweating with periodic use of solution Reference - Br Med J 1978 Jul 8;2(6130):84 aluminum salt thermophobic foam reported to reduce sweating in patients with axillary or palmar hyperhidrosis (level 3 [lacking direct] evidence) based on uncontrolled trial 20 patients with axillary or palmar hyperhidrosis applied 20% aluminum salt foam (VersaFoam) nightly for 1 week then 3 times per week during second week Minor iodine sweat score reduced from baseline both in patients with axillary hyperhidrosis by 50% (p = 0.0002) and palmar hyperhidrosis by 53% (p = 0.0047) foam use reported to improve Dermatology life Quality Index for patients with axillary but not palmar hyperhidrosis Reference - Curr Med Res Opin 2005 Dec;21(12):1949 hydrocortisone 1% cream may reduce inflammation if irritation occurs with antiperspirants, but recommended use limited to maximum 2 weeks(1) glycopyrrolate glycopyrrolate 0.5% topical cream may reduce diabetic gustatory sweating (level 2 [mid-level] evidence) based on small randomized crossover trial 14 patients with diabetes (mean age 46 years) randomized to glycopyrrolate 0.5% topical cream vs. placebo for 2 weeks, then crossed over to other group after 1-week washout 13 patients completed trial comparing glycopyrrolate vs. placebo complete disappearance of sweat response to food challenge in 5 patients (38%) vs. 1 patient (8%) (NNT 4) median number of gustatory sweating episodes 13.5 vs. 27.5 (p = 0.004) median sweat production 0.74 mg/cm2 vs. 4.07 mg/cm2 (p = 0.008) Reference - Diabetologia 1997 Mar;40(3):299 glycopyrrolate 0.5% topical solution applied daily reported to reduce craniofacial hyperhidrosis in case report (South Med J 2002 Jul;95(7):756) aldehyde agents (formaldehyde, glutaraldehyde) of limited use because of allergic sensitization and skin irritation(4) topical botulinum toxin type A may be associated with reduction in sweating for patients with axillary hyperhidrosis (level 2 [mid-level] evidence) based on small randomized trial 12 patients (mean age 35 years) with primary axillary hyperhidrosis had axillae randomized to topical botulinum toxin A (Botox) 200 units vs. placebo on contralateral side sweat production measured gravimetrically data for 10 patients analyzed at 4 weeks, sweat production reduced by mean 65.3% in topical botulinum toxin group vs. mean 25.3% in control group (p < 0.05) Reference - Dermatol Surg 2007 Jan;33(1 Spec No):S76 Botulinum toxin injections: American Academy of Neurology recommendations for botulinum neurotoxin in treatment of autonomic disorders botulinum neurotoxin should be offered as treatment option to patients with axillary hyperhidrosis (Level A) botulinum neurotoxin should be considered as treatment option for patients with palmar hyperhidrosis (Level B) axillary hyperhidrosis Botox FDA approved for primary axillary hyperhidrosis botulinum toxin type A intradermal injections are effective for up to 16 weeks and for improving quality of life (level 1 [likely reliable] evidence) Botox and Dysport appear equally effective (level 2 [mid-level] evidence) 100-unit dose and 200-unit dose injections appear equally effective (level 2 [mid-level] evidence) botulinum toxin type A injection appears more effective than topical aluminum chloride in focal axillary hyperhidrosis (level 2 [mid-level] evidence) botulinum toxin type B reported to reduce sweating and improve quality of life (level 3 [lacking direct] evidence) for palmar hyperhidrosis botulinum toxin type A injection appears to reduce palmar hyperhidrosis (level 2 [mid-level] evidence) Botox and Dysport appear equally effective (level 2 [mid-level] evidence) 50-unit dose and 100-unit dose injections appear equally effective, but associated with dose-dependent reduction in finger pinch strength (level 2 [mid-level] evidence) botulinum toxin type B injection may be associated with improved quality of life (level 2 [mid-level] evidence) gustatory sweating may be reduced by botulinum toxin type A intracutaneous injection (level 2 [mid-level] evidence) see Botulinum toxin for hyperhidrosis for details Systemic medications: systemic treatments generally not recommended (grade C recommendation [lacking direct evidence]) for generalized hyperhidrosis, management usually directed at underlying cause(1) beta blockers might have role in hyperhidrosis due to anxiety, but no published evidence(1) systemic anticholinergic agents not usually recommended for focal hyperhidrosis due to adverse effects(1,4) glycopyrrolate 1-2 mg 3 times daily may be considered in severe cases(3) clonidine 0.6-1.2 mg/day in 2-3 divided doses reported as consideration for craniofacial or gustatory hyperhidrosis (level 3 [lacking direct] evidence) based on 2 case reports complete remission of facial and scalp hyperhidrosis reported in 1 patient with combination of clonidine hydrochloride (0.3-0.4 mg, with 0.25 mg taken at bedtime) plus topical aluminum chloride 20% in anhydrous ethyl alcohol (Drysol) (South Med J 2000 Jan;93(1):68) significant reduction in gustatory facial sweating reported with clonidine 0.2 mg/day patch in randomized placebo-controlled n-of-1 trial (Arch Phys Med Rehabil 1996 Sep;77(9):906) oral methanthelinium bromide may reduce axillary hyperhidrosis (level 2 [mid-level] evidence) based on small randomized trial published in German 41 patients (mean age 28 years) with hyperhidrosis randomized to methanthelinium bromide (Vagantin) 50 mg twice daily vs. placebo for 4 weeks sweat production measured gravimetrically mean axillary sweat production decreased from 89.2 mg/minute to 53.3 mg/minute with methanthelinium bromide (p = 0.02) mean axillary sweat production unchanged (from 60.7 mg/minute to 59.1 mg/minute) with placebo no difference between groups for palmar sweat production dry mouth reported significantly more often in treatment group Reference - J Dtsch Dermatol Ges 2004 May;2(5):343 full-text [German] Surgery: Problems with evidence base for surgical management of hyperhidrosis: no clear assessment of overall impact of surgery in general population of patients with primary hyperhidrosis (trials primarily compare different levels of sympathetic chain disruption rather than role of surgery) lack of uniform definitions and outcome measures marked heterogeneity in trial populations Reference - Thorac Surg Clin 2008 May;18(2):209 Thoracic sympathectomy: destroys sympathetic ganglia by excision, clamping, transection or ablation with cautery or laser(4) limited by high incidence of compensatory hyperhidrosis(4) endoscopic thoracic sympathetic block may improve quality of life in upper limb hyperhidrosis (level 2 [mid-level] evidence) based on uncontrolled study with all-or-nothing response prospective study of 223 limited endoscopic thoracic sympathetic block at T4 procedures in 112 patients for upper limb hyperhidrosis 103 patients had palmar hyperhidrosis 87 patients had axillary hyperhidrosis 75 patients had combined hyperhidrosis mean follow-up 21.9 months after surgery all 103 patients with palmar hyperhidrosis were completely or almost dry after surgery side effects included compensatory sweating (17%) and gustatory sweating (28.3%) Reference - Br J Surg 2006 May;93(5):582 endoscopic thoracic sympathectomy via resection, transection, ablation, or clipping may be equally effective (level 2 [mid-level] evidence) based on randomized trial without blinding 80 male patients (mean age 22 years) with primary hyperhidrosis treated by endoscopic thoracic sympathectomy were randomized to 1 of 4 techniques (20 patients each had resection, transection, ablation, and clipping) overall success rates 96.3% for isolated palmar hyperhidrosis 95.7% for palmar and axillary hyperhidrosis 66.7% for palmar and facial/scalp hyperhidrosis no differences in success rates between groups patients in clipping group had significantly shorter duration of surgery Reference - Thorac Cardiovasc Surg 2008 Jun;56(4):210 comparisons of different levels of sympathetic chain disruption for patients with palmar hyperhidrosis all patients at all levels of sympathetic chain disruption had resolution of palmar hyperhidrosis in these trials, differences reported with respect to compensatory hyperhidrosis sympathectomy at level T2 and level T2-T3 associated with similar rates of compensatory hyperhidrosis (level 2 [mid-level] evidence) based on small randomized trial 25 patients (mean age 32 years) with palmar hyperhidrosis had left or right side randomized to sympathectomy at T2-T3 level followed by T2 level sympathectomy on contralateral side patients followed for mean 23 months (range 2-65 months) all patients reported bilateral symmetrical resolution of palmar hyperhidrosis compensatory hyperhidrosis occurred in 80% and was bilateral and symmetrical Reference - Surg Endosc 2007 Oct;21(10):1768 sympathectomy at T4 level associated with reduced rate of compensatory hyperhidrosis compared to T3 level (level 2 [mid-level] evidence) based on 2 randomized trials without blinding 163 patients with palmar hyperhidrosis randomized to sympathectomy at T4 level vs. T3 level all patients reported resolution of palmar hyperhidrosis after surgery and no recurrence during mean 13.8-month follow-up comparing rates of compensatory hyperhidrosis with sympathectomy at T4 level vs. T3 level none in 55.3% vs. 29.5% (p = 0.001, NNT 4) mild in 37.6% vs. 47.4% (not significant) moderate in 7.1% vs. 23.1% (p = 0.004, NNT 7) Reference - Chin Med J (Engl) 2007 Sep 20;120(18):1574 full-text 106 patients with primary palmar hyperhidrosis randomized to sympathectomy at T4 level vs. T3 level patients followed for mean 8.6 months all patients reported resolution of palmar hyperhidrosis comparing sympathectomy at T4 vs. T3 level compensatory sweating occurred in 21.6% vs. 45.6% (p < 0.05, NNT 5) dry hand problems occurred in 5.4% vs. 25.8% (p < 0.05, NNT 5) Reference - Zhonghua Yi Xue Za Zhi 2006 Sep 5;86(33):2318 [Chinese] sympathectomy at T3 level associated with reduced rate of severe compensatory hyperhidrosis compared to T2 level (level 2 [mid-level] evidence) based on randomized trial with allocation concealment not stated 60 patients with palmar hyperhidrosis randomized to sympathectomy at T3 level vs. T2 level performed by same surgical team and with standardized technique patients followed at 1 and 6 months postoperatively all patients reported resolution of palmar hyperhidrosis at 1-month and 6-month follow-up comparing T3 level vs. T2 level compensatory hyperhidrosis at 1 month in 90% vs. 86.7% (not significant) compensatory hyperhidrosis at 6 months in 96.6% vs. 100% (not significant) severe compensatory hyperhidrosis at 1 month in 0 vs. 33% (p < 0.05, NNT 3) severe compensatory hyperhidrosis at 6 months in 10% vs. 33% (p < 0.05, NNT 5) Reference - J Vasc Surg 2005 Aug;42(2):281 sympathectomy at T3 level associated with reduced rate of severe compensatory hyperhidrosis compared to T2-T4 level (level 2 [mid-level] evidence) based on randomized trial without blinding 232 patients with primary palmar hyperhidrosis randomized to sympathectomy at T3 level vs. T2-T4 level patients followed at 1 and 12 months all patients reported resolution of palmar hyperhidrosis after surgery and at follow-up comparing sympathectomy at T3 vs. T2-T4 level rate of satisfied or very satisfied patients 96.6% vs. 89.6% (p < 0.05, NNT 15) rate of dissatisfied or very dissatisfied patients 3.4% vs. 10.4% (p < 0.05, NNT 15) rate of severe compensatory sweating 3% vs. 10% (p < 0.05, NNT 15) Reference - Ann Thorac Surg 2008 May;85(5):1747, commentary can be found in Ann Thorac Surg 2008 May;85(5):1751 sympathectomy at T3 or T3-T4 level may be associated with reduced rate of compensatory hyperhidrosis compared to T2-T4 level (level 2 [mid-level] evidence) based on randomized trial not available in English 398 patients aged 10-53 years with palmar hyperhidrosis randomized to sympathectomy at 1 of 3 levels 60 patients at T3-T4 level 131 patients at T3 level 207 patients at T2-4 level all patients reported resolution of palmar hyperhidrosis compensatory hyperhidrosis rates 6.7% with T3-T4 level 5.3% with T3 level (not significant vs. T3-T4 level) 28% with T2-T4 level (p < 0.01, NNH 4) Reference - Zhonghua Yi Xue Za Zhi 2006 Sep 5;86(33):2315 [Chinese] sympathectomy at T4 level or T3-T4 level appears equally effective for axillary hyperhidrosis, but T4 level associated with less compensatory hyperhidrosis (level 2 [mid-level] evidence) based on randomized trial with allocation concealment not stated 62 patients with axillary hyperhidrosis randomized to sympathectomy at T4 level vs. T3-4 level performed by same surgical team and with standardized technique patients followed at 1 and 6 months postoperatively no treatment failures occurred comparing patients treated with T4 vs. T3-4 level sympathectomy compensatory hyperhidrosis at 1 month in 56.7% vs. 90.6% (NNT 3) compensatory hyperhidrosis at 6 months in 43% vs. 86% (NNT 3) moderate or severe compensatory hyperhidrosis at 1 month in 3.3% vs. 46.9% (NNT 3) moderate or severe compensatory hyperhidrosis at 6 months in 6.7% vs. 34.4% (NNT 4) patients reporting complete satisfaction at both 1 month and 6 months 88% vs. 97% (not significant) Reference - J Vasc Surg 2007 Jan;45(1):130 Axillary tissue liposuction and curettage: removal of sweat glands in dermis-subcutaneous fat junction(2) small incision followed by superficial curettage or liposuction(2) procedure has potential for scarring(2) subcorial curettage reported to reduce sweat rates in patients with axillary hyperhidrosis (level 3 [lacking direct] evidence) based on uncontrolled trial 42 patients with axillary hyperhidrosis had subcorial curettage, sweat rates recorded at baseline and 4-8 weeks after surgery for 38 patients in 29 axillae with baseline sweat rate > 50 mg/minute (mean 85.6 mg/minute), mean sweat rate reduced to 21.6 mg/minute (p < 0.0001) in 22 axillae with baseline sweat rate 25-50 mg/minute (mean 36.8 mg/minute), mean sweat rate reduced to 16.5 mg/minute (p < 0.0001) no significant reduction in 25 axillae with baseline sweat rate < 25 mg/minute Reference - Dermatol Surg 2002 Nov;28(11):1022 Consultation and referral: consider referral to dermatologist if topical antiperspirants are ineffective or intolerable(1) consider referral to mental health provider as appropriate (Prog Neuropsychopharmacol Biol Psychiatry 2002 Dec;26(7-8):1327) Other management: Iontophoresis: introduction of ions into skin by electric current mode of action unclear second-line treatment for focal palmoplantar hyperhidrosis(4) contraindicated in patients who are pregnant or who have a pacemaker(4) iontophoresis with at-home device (Drionic unit) might reduce area of focal hyperhidrosis (level 2 [mid-level] evidence) based on randomized trial without blinding 22 patients with 27 treatment sites were randomized to right-left side comparison of Drionic treatment vs. no treatment treatment sites were exposed to Drionic unit for 30 minutes twice daily for 5 days, then 30 minutes once daily until reduction in sweating noted 24 treated sites showed ≥ 50% subjective clinical improvement, only these 24 sites were analyzed mean areas of sweat imprint comparing Drionic unit vs. control at 1 month 5.07 inches2 vs. 8.03 inches2 at 27 sites analyzed (p < 0.01) 6.46 inches2 vs. 9.9 inches2 at 10 palms analyzed (p < 0.05) 4.07 inches2 vs. 6.7 inches2 at 9 soles analyzed (not significant) 4.26 inches2 vs. 6.7 inches2 at 8 axillae analyzed (not significant) minor side effects included discomfort, vesicles, erythematous papules, scaling Reference - J Am Acad Dermatol 1987 Apr;16(4):828 at-home iontophoresis device appears as effective as traditional galvanic generator for long term control of palmoplantar hyperhidrosis (level 2 [mid-level] evidence) based on non-randomized trial 71 patients with palmoplantar hyperhidrosis treated with tap water iontophoresis (40 using galvanic generator, 31 using at-home device) hyperhidrosis was controlled after 10-12 treatments with at-home device no obvious differences in efficacy between devices transient side effects included slight discomfort during treatment and mild skin irritation Reference - Dermatologica 1987;175(3):126 bilateral glycopyrrolate iontophoresis appears superior to unilateral glycopyrrolate iontophoresis which appears superior to tap water iontophoresis in terms of duration of treatment effect (level 2 [mid-level] evidence) based on small randomized trial 20 patients with palmoplantar hyperhidrosis randomized in single-blinded right-left trial median duration of self reported palm dryness 3 days with tap water iontophoresis 5 days with unilateral glycopyrrolate iontophoresis 11 days with bilateral glycopyrrolate iontophoresis Reference - Australas J Dermatol 2004 Nov;45(4):208 iontophoresis with botulinum toxin type A may reduce sweating in patients with primary palmar hyperhidrosis (level 2 [mid-level] evidence) based on small randomized trial 8 patients with primary palmar hyperhidrosis had palms randomized to iontophoresis with botulinum toxin (Botox) vs. iontophoresis with saline placebo gravimetry assessed at baseline and at 14 days with botulinum toxin iontophoresis 3 palms had dramatic improvement (sweating reduced from 100-450 mg/5 minutes to < 50 mg/5 minutes) 3 palms had some reduction in sweating 2 palms had increase in sweating with saline iontophoresis 1 palm had reduction in sweating 7 palms had increase in sweating patient assessment of treatment effect on 100-point analogue scale improved from mean 68 at baseline to mean 45 (p < 0.01) no significant effect on patient assessment of treatment effect in palms treated with iontophoresis and placebo Reference - J Am Acad Dermatol 2006 Nov;55(5 Suppl):S115, commentary can be found in J Am Acad Dermatol 2007 Dec;57(6):1097, J Am Acad Dermatol 2008 Apr;58(4):e1 alternating current (AC) iontophoresis reported to be effective for palmoplantar hyperhidrosis without side effects (level 3 [lacking direct] evidence) based on uncontrolled trial of prototype AC device for 8 weekly treatments Reference - J Dermatol 2003 Jun;30(6):444 Alternative treatments with little to no evidence: relaxation techniques(4) hypnosis(4) biofeedback training(4) Follow-up: routine photographs of starch-iodine test results may be used to assess treatment response(3) Prevention and Screening Prevention: identify and avoid triggers (heat, spicy food, intense concentration, strong emotions)(1) References including Reviews and Guidelines ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿ 2．多汗症について 多汗症の分類には、特発性である一次性の多汗症と、 原因となる基礎疾患がある二次性の多汗症にわけられます。 特発性多汗症の発症部位は、手掌（てのひら）、足底、腋窩（わきの下）、顔面などです。 その診断基準としては、 ・発症年齢が25歳以下であること ・両側対称性であること ・睡眠中は発汗が止まっていること ・家族歴があること ・週1回以上の多汗のエピソードがあること ・日常生活に支障をきたす程の汗であること 以上から該当が2項目以上で診断されると2004年のJAAD＊で述べられています。 ＊JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY また問診では、以下のような事例が聴取されます。 社会生活、学校生活、または対人関係での問題として、 ・美容師が手が濡れてカットできない 　・パソコン、携帯など電気機器がこわれる 　・試験の際答案用紙がやぶれる 　・握手ができない など 非常に日常生活のQOL（クオリティ・オブ・ライフ）が損なわれています。 （二次性多汗症の原因としては薬剤性、感染症、甲状腺機能亢進、脳梗塞、中枢・末梢神経障害などがあります。） ページTOPへ戻る 3.　検査方法について 主に簡易発汗紙を用いた検査で発汗量を測定しており、 おおよそ下記のようにわかれます。 重症：　 全体にべったり染まる 中等症： 全体に染まる 軽症： 指腹、掌辺縁が染まる ページTOPへ戻る 4．治療について　 　　　　上から順に、ローリスクローリターンな治療、下にいくにつれてハイリスクハイリターンな治療になります。 治療方法 長所 短所 塩化アルミニウム溶液 安価・簡単 効果薄い、皮膚炎 イオントフォトレーシス 安価・簡単 手間がかかる、 治療機器が必要 ボツリヌス毒素局注 効果が高い ３～６ヶ月有効 痛い、高価、 年齢制限、副作用 また、上記の治療法ではコントロール不十分な例には、ETS（胸部交換神経遮断術）などがあり、紹介もしています。 塩化アルミニウム溶液 塩化アルミニウムの費用が安いこと、手軽に自宅で行える利点を生かしたODT（閉鎖密閉療法）で、 単純塗布と比べ、重症例にも対応できます。 （院内の和同会薬局で販売しています。　100ml　800円） 施行方法 手順１： 就寝前に 手順２： 素手に布手袋をはめます 手順３： 塩化アルミニウム溶液を掌側に染み込ませます 手順４： 布手袋の上から、ゴム手袋をはめて就寝します。 （夜間密封療法） 翌日は起床後、石鹸で手を洗います。 注意：刺激皮膚炎などがおこることがあります。必ず説明を受けて行ってください。 イオントフォレーシス 直流電流を通電させることによって、表皮障害から表皮内汗腺が閉塞する説や、 陽極側での電気分解した水素イオンの作用である機序が考えられています。 医療用の高出力のものを用いると週1～2回の通院で約8回程度行うと効果がみられ、 中等症から重症に有効であります。 ペースメーカー装着者や妊婦など禁忌以外は広く使用可能で、 塩化アルミニウム溶液に皮膚炎を起こす症例に用いたり、外用と併用することで相乗効果も得られます。 通院できない患者に対しては、現在のところ米国からドライオニック®という医療機器を 個人輸入して自宅で行ってもらう方法をとっています。 製品についてはインターネットで確認いただけます。 ドライオニック® BOTOX®（ボツリヌス毒素局注） 上記方法でのコントロールが悪い場合、適切な診察の上でBOTOX®を行っています。 ボツリヌス毒素製剤です。 私達の施設では、アラガン社製のボトックス注を使用しています。 これは国内で唯一厚生労働省に認可されているボツリヌストキシン製剤であり、 国内では眼瞼痙攣、片側顔面痙攣、痙性斜頚のみ保険適応となっているため、 多汗症には医師が輸入代行業者を通じて購入するのが一般的です。 使用に関しては規定の講習実技セミナーを受けた上で、 使用前には十分の説明の上、同意を取るインフォームドコンセントが必須です。 当科では日帰り手術であり、麻酔は外用麻酔薬による浸潤麻酔と冷却を併用しています