Excessive Sweating – Hyperhidrosis. Is treating upper cervical instability the missing treatment?
Ross Hauser, MD
A patient will often contact us that they have a problem with sweating. Their clothes are soaked, they wake up in the middle of the night soaked. They are constantly and continually sweating. They have a diagnosis of hyperhidrosis or simply they sweat a lot and for unknown reasons.
In a search for unknown reasons, the following possible causes were ruled out by various tests.
- Tests for:
- Hormone disorders
- Thyroid problems
- Infectious disease
- and menopausal problems, NOTHING comes back positive, so what can it be?
Regardless of what is causing it, Hyperhidrosis causes significant quality of life issues.
If you suffer from Hyperhidrosis you will likely not need a medical study to tell you how miserable this condition is. A medical study may be helpful in convincing others. University hospital researchers at the University of Denmark published an August 2022 paper in the journal Quality of Life Research (1). These are the learning points for doctors:
- Hyperhidrosis has been associated with a reduced health-related quality of life (HRQoL).
- In this study of the general population, 9.1% of people had self-reported hyperhidrosis and 0.2% (2 out of 1000) had hospital-diagnosed hyperhidrosis.
- Self-reported hyperhidrosis was associated with a reduced mental health-related quality of life and physical health-related quality of life. Hospital-diagnosed hyperhidrosis was associated with a reduced mental health-related quality of life.
The researchers concluded: “Hyperhidrosis is associated with a reduced health-related quality of life, independently of confounders or mode of diagnosis. This supports an approach primarily targeting hyperhidrosis.”
What this study says is that for sufferers, doctors should try to target the cause of hyperhidrosis. In this article, we will try to show that one cause is cervical spine instability stretching, and compressing nerves that regulate sweating.
Sweating problems are a symptom among many.
If you have a problem with sweating, it can be caused by many factors including those mentioned above. But if you suffer from excessive sweating as one of many other symptoms, the causes have to be looked at in neurology. For many people we see, especially those with moderate to severe neck problems, we start looking for clues that the sweating is coming from cervical spine instability.
We do realize for some of these people, sweating becomes a primary concern and they become very self-conscious of people looking at their excessively wet clothes. Of the many of their symptoms that people want to be treated, is the problem of excess sweating.
Now, let’s look at a December 2022 study (2) that helps us start linking these ideas together. Here doctors from the Zealand University Hospital and the University of Copenhagen in Denmark linked psychiatric diseases such as depression and personality disorders, and, speculated that chronic heart disease and sweating problems may be linked to sympathetic nervous system overactivity. The point of the researchers is that the doctors were looking for possible answers towards a disease trajectory, i.e., does excessive sweating predict heart disease, and does depression cause excessive sweating? There were no concrete answers for understanding hyperhidrosis in this context other than to open doors for looking at neurologic-like, psychiatric-like, and sympathetic nervous system overactivity symptoms and conditions in understanding a patient’s sweating problems. In our research neurologic-like, psychiatric-like, and sympathetic nervous system overactivity symptoms and conditions may be a problem of nerve compression caused by cervical spine instability. This can be suggested by the number of hyperhidrosis patients who complain of neck and back pain.
Next, let’s explore the confusion and uncertainty in the diagnosis of hyperhidrosis.
In 36.8% of the patients with local hyperhidrosis, there was a delay in diagnosis of more than 10 years.
A January 2022 paper (3) from doctors at Oulu University Hospital in Finland gives a profile of the patients they saw with hyperhidrosis.
- The average age of patients with local hyperhidrosis was 27.9 years and the majority were female (62.7%).
- The most common anatomical site of symptoms in the youngest age group was the palms, whereas the axillae (armpits) were a more common site in advanced age.
- Depression was a common comorbidity in both local (11.6%) and generalized hyperhidrosis (28.6%).
- Anxiety affected 12.7% of patients with generalized hyperhidrosis.
- In 36.8% of the patients with local hyperhidrosis, there was a delay in diagnosis of more than 10 years.
- The most commonly used treatments included topical antiperspirants, iontophoresis, and botulin toxin.
NOTHING comes back positive, so what can it be? I am sweating all the time. The answer for some is cervical spine instability
Listen to these people’s stories. They have issues with sweating among many different symptoms. Many have a diagnosis of hyperhidrosis – excessive sweating But their sweating and other symptoms reflect a common origin, a problem in the neck.
I sweat when I need to urinate
Almost 15 years ago I had C4 -C7 laminectomy for spinal cord compression, chronic pain, and bladder issues. The surgery did not go so well. I moved onto a C4 -C7 soon after the first surgery. That surgery did not go so well as I continued to have cervical radiculopathy. My current problems include much excessive sweating when I have to urinate. My situation is currently going downhill fast.
Extreme sweating is very difficult to manage, I have to change my clothes many times a day.
I have a diagnosis of Occipital neuralgia. My doctors tell me I have compression at C2. I have headaches, syncope (fainting), nausea and vomiting, blurred and double vision, swallowing difficulties, migraines, heat intolerance, and extreme sweating. Extreme sweating is very difficult to manage, I have to change my clothes many times a day.
Ehlers-Danlos syndrome and Hyperhidrosis
For some people with multiple symptoms or concerns, each problem may be treated as its own entity. This may be the case with Hyperhidrosis. Here is another story:
I have been diagnosed with Ehlers-Danlos syndrome, and I have symptoms of blurred vision, eye pain, hyperhidrosis, migraines, neck pain, and burning sensation in the face, neck, and upper torso. I am on a lot of medications. For hyperhidrosis, I have been prescribed oxybutynin. It hasn’t worked.
Symptomatic treatment for Hyperhidrosis
In this section, we are going to take a medical journey that many people take, maybe you did too. It is a list of treatments that you may have tried for your sweating problem. These treatments are considered Symptomatic. They only address the symptoms and not the underlying cause of your sweating. Many of these treatments will be successful, but many will not. If you are reading this article and these are treatments you have tried and they have been less than successful, here are the reasons that can be explored. Ultimately, for some people, we will suggest that the problem of sweating and other neurological type symptoms mentioned above are problems of the cervical spine.
Oral oxybutynin for the treatment of Hyperhidrosis
According to the U.S. National Library of Medicine’s MedLine Plus, Oxybutynin is used to treat overactive bladder, frequent urination, urgent need to urinate, and inability to control urination. In March 2015, a team of researchers published in the journal Skin Appendage Disorders,(4) that Oxybutynin, an anticholinergic drug (a neurotransmitter blocker) was emerging as a treatment of hyperhidrosis. At the time, several studies documented that it is effective in hyperhidrosis treatment. For some people, oxybutynin may be effective. For others not. Let’s look at the research:
In August 2020, researchers published their observations on Oral oxybutynin for the treatment of Hyperhidrosis. The research appears in the journal Dermatologic Therapy. (5)
Here are the learning points:
- Oral oxybutynin is an effective and safe treatment for the treatment of hyperhidrosis.
- In some patients, however, there is a loss of effectiveness during prolonged and extended usage of the treatment.
To help understand why the effectiveness of oxybutynin wore off, the researchers looked at the clinical charts of patients who started oxybutynin treatment for their sweating problems and why these people stopped using the medication.
- The development of tolerance was suspected in 18 patients (8.5%) of the 211 who had previously responded positively to oxybutynin.
- Thirteen patients abandoned oxybutynin due to its lack of efficacy and five had to increase the dose in order to maintain efficacy.
- In seven patients, tolerance to the drug appeared in the first year of treatment, while in the remaining 11, tolerance appeared later. Most patients achieved and maintained good control of hyperhidrosis with long-term oxybutynin. However, in some cases, the efficacy of the drug decreases. This study did not produce findings enabling a suggestion to predict who would have a loss of treatment effectiveness.
In our opinion, we would suspect that the people who did not respond to oxybutynin in the long term may have had a cervical spine issue. Oxybutynin does not treat problems of the cervical spine.
Oral glycopyrrolate for hyperhidrosis
The same group of researchers published in the August 2020 issue of the journal Dermatologic Therapy (6), then explored the use of oral glycopyrrolate for people who did not respond to oxybutynin.
Here are the learning points of that research
- Oral glycopyrrolate is a safe and effective alternative if oxybutynin fails.
- A total of 58 patients (41 women), with an average age of about 36 were included in the study.
- These patients were followed for The median follow-up period was 32 months.
- At 3 months, 70.7% of the patients had responded to treatment (excellent response: 75.6%), and adverse (side-effects) were reported by 70.7%.
- At 12 months, 53.4% had responded (excellent response: 74.2%), with adverse effects in 70.9%.
- The variables associated with poorer adherence were affected areas: palms of the hands, soles of the feet, and armpits.
- The only variable associated with greater adherence was the generalized presence of hyperhidrosis.
So here we have treatments that many people have had. The ones who had success with oxybutynin or glycopyrrolate, are probably not the people we see at our center. We see people, perhaps like yourself, who continue to have problems with excessive sweating following these medications.
Iontophoresis and curettage
A February 2022 paper in the International Journal of Dermatology (7) wrote of the limited progress being made in hyperhidrosis treatments.
The treatments discussed were iontophoresis, botulinum toxin, anticholinergic medication, curettage (removal of the skin layer and the sweat glands within it), and energy-based technologies (to heat the sweat glands and possibly disable them).
Note: Many of you reading this article will be well aware of the Iontophoresis procedure. It may have been recommended to you after a failure of various strengths or prescriptions of antiperspirants or if you have significant palmoplantar sweating. In iontophoresis treatment, a medical device passes an electrical current through water and onto the skin.
Progress in the diagnostics and etiology of hyperhidrosis is limited with the same being true for treatment. In a 5-year-old systematic review, it was concluded that there was moderate-quality evidence to support the use of botulinum toxin for axillary hyperhidrosis.
Primary care physicians and the problem of where to send palmar hyperhidrosis patients.
Doctors at the University of Chicago noted the difficulties among doctors in sending people with palmar hyperhidrosis to the right specialist. Writing in the journal Interactive Cardiovascular and Thoracic Surgery (8) in a May 2022 study, the researchers comment:
- The majority of primary care physicians (31/53; 58%) would prescribe topical aluminum chloride for palmar hyperhidrosis, whereas 28 of 53 (53%) would refer such patients to dermatology.
- Twenty-three of 53 (43%) physicians would refer such patients to surgery if conservative management failed:
- 18 (78%) to plastic surgery,
- 4 (17%) to general surgery and none to thoracic surgery.
It is the thoracic surgeon that does the endoscopic thoracic sympathicotomy.
Endoscopic thoracic sympathicotomy the gold standard – compensatory hyperhidrosis – a frequent side-effect
A January 2022 paper in the Annals of Palliative Medicine (9) examined the long-term quality-of-life benefits of Endoscopic thoracic sympathicotomy in the treatment of Palmar hyperhidrosis.
The study authors write: Endoscopic thoracic sympathicotomy is safe and efficient as the gold standard treatment for Palmar hyperhidrosis. So far, the long-term change in quality of life after surgery is not really known – nor is the true benefit of the surgery. To answer these questions the authors investigated the long-term outcome of Endoscopic thoracic sympathicotomy by comparing their preoperative quality of life with a follow-up quality of life.
Results: After an average follow-up of 14 months, improvement in quality of life was reported in 90.7% of patients. Compared to preoperative quality of life, postoperative quality of life was significantly improved. A higher quality of life score was noticed in patients with a more severe Palmar hyperhidrosis at diagnosis, whereas no significant difference was observed among postoperative quality of life regarding the severity of Palmar hyperhidrosis. Subclinical compensatory hyperhidrosis (the most common complication of sympathetic surgery) occurred in 94.6% of post-Endoscopic thoracic sympathicotomy cases after long-term follow-up.
Conclusions: Improvement in quality of life sustained for a long-term period after receiving Endoscopic thoracic sympathicotomy for Palmar hyperhidrosis. Almost all patients developed subclinical compensatory hyperhidrosis on other body sites in the long run, with an impairment in quality of life correlating with the severity of compensatory hyperhidrosis. Further investigations on the developing patterns of compensatory hyperhidrosis and clinical coping strategy are warranted to improve the long-term outcome of Endoscopic thoracic sympathicotomy.
Patients may regret choosing surgery and surgeons may hesitate to suggest sympathectomy
A January 2022 paper in the journal Frontiers in Surgery (10) addresses the concerns regarding the potential to develop compensatory hyperidrosis after thoracoscopic sympathetic interruption or Thoracoscopic Sympathectomy.
Despite advances in surgical techniques, compensatory hyperidrosis remains the most troublesome postoperative side effect, which occasionally causes patients to regret choosing surgery and surgeons to hesitate to suggest sympathectomy as an upfront treatment for compensatory hyperidrosis, especially for craniofacial hyperhidrosis
Postoperative compensatory hyperhidrosis is reported in 50–90% of patients depending on the studies and is experienced “severe” in as many as 35% of patients.
Compensatory hyperidrosis development is poorly understood. Currently, there is no effective treatment for compensatory hyperidrosis after thoracic sympathectomy. Indeed, there have been several attempts to reduce compensatory hyperidrosis, such as both preoperative and postoperative strategies. Among the preoperative ones, limited-level sympathectomy or lower-level sympathectomy have been the most adopted.
Compensatory hyperhidrosis onset may be prevented or mitigated through several actions ranging from prevention to re-surgery. Prevention may be obtained by identifying subjects at higher risk and/or targeting nerve interruption levels on the basis of single patient characteristics. On the contrary, surgical treatment may consist of techniques aimed to reverse the effects of previous sympathetic interruption.
In the past decade, no one of these solutions took over, and compensatory hyperhidrosis is still the major cause of dissatisfaction for patients.
Botox® and the armpits
Here is another case:
I have a physically demanding job, I use my upper body all day long. I worked through a lot of neck and shoulder pain. One day I started noticing that I was having a hard time swallowing. Then I started noticing what I did swallow, I was not digesting. I was sent to a gastroenterologist to treat what was termed “serious acid reflux.” Then I developed a burning sensation in my skin, sensitivity to loud noises, and bright lights. My neck pain continued to get worse and I am constantly cracking my neck. Then I developed this sweating problem. My palms and underarms are always drenched with sweat. I am not wearing cotton gloves to help absorb the sweat, I change my shirt numerous times throughout the day.
I was sent to a dermatologist and he confirmed severe hyperhidrosis. He suggested a prescription-strength antiperspirant, I did not even know such a thing existed. That was not helpful. Then I was told that Botox® injections into my armpits may help. The Botox® would act as a nerve block to block “sweating messages” from going from my brain to my armpits. Then as a last resort, there is surgery to remove the sweat glands.
Botox® injections for axillary hyperhidrosis (excessive armpit sweating) can be very effective for many people. An August 2020 study (11) from Tallaght University Hospital, Dublin, Ireland examined patients who had 5-year follow-ups and treatments of Botox® injections for armpit sweating and found that for many people this would be a successful long-term treatment for their armpit sweating.
Like the people who had successful treatments of glycopyrrolate or oxybutynin, the people who have success with Botox® injections are typically not the people we see in our offices. Where one treatment will work for one condition is usually not in the realm of people we see with cervical spine instability. Let’s look at one more example of treatment.
Botox and Craniofacial hyperhidrosis
A March 2021 study in The Journal of international medical research (12) discussed the case of a 32-year-old woman with uncontrolled craniofacial hyperhidrosis
“Craniofacial hyperhidrosis causes sweating of the face and scalp due to excessive action of the sweat glands and manifests when patients become tense/nervous or develop an elevated body temperature. If noninvasive treatments are ineffective, invasive treatments such as a sympathetic block and resection are considered.”
Note: Doctors may perform a sympathectomy. This is major surgery where nerve networks to the sweat glands are severed and destroyed.
“A 32-year-old woman with no specific medical history was referred for uncontrolled craniofacial hyperhidrosis that included excessive sweating and hot flushing. Physical examination showed profuse sweating and infrared thermography showed higher temperature in the neck and face than in the trunk. The patient underwent several stellate ganglion blocks, and her symptoms improved; however, the treatment effect was temporary.”
Note: A stellate ganglion block numbs the ganglia, limiting its ability to send pain signals.
“Botulinum toxin was then injected into the stellate ganglion. At the time of this writing, her sweating had been reduced for about 6 months and she was continuing to undergo follow-up.”
OnabotulinumtoxinA injections into the sweat glands
There are favorable studies on the use of onabotulinumtoxinA or Botox injection. However, while effective for many it is not effective for all. The onabotulinumtoxinA is treating symptoms and not underlying issues. A July 2023 study (13) summarizes the use of onabotulinumtoxinA in the sweat glands. “Therapies available before onabotulinumtoxinA (injections) were generally topical, with limited effectiveness, application-site skin reactions, and frequent, time-consuming treatments. Intradermal injection of onabotulinumtoxinA to treat sweat glands arose as a novel therapeutic approach. . . Compared with placebo, onabotulinumtoxinA treatment significantly reduced axillary sweat production and axillary hyperhidrosis severity. The effects of onabotulinumtoxinA occurred rapidly, within 1 week after injection, and lasted more than 6 months.”
Magnesium, vitamin D, the autonomic nervous system, and primary hyperhidrosis
A paper in the January 2022 issue of the Journal of Cosmetic Dermatology (14) made a possible connection between the autonomic nervous system and primary hyperhidrosis
Excessive sweating is considered primary hyperhidrosis if it is triggered by emotional states without any thermogenic (heat) or other underlying disease from the eccrine (sweat) glands. This may be due to dysfunction in the autonomic nervous system.
In this paper, researchers investigated the relationship between Vitamin D and magnesium deficiency and the risk of anxiety and depression in patients with primary hyperhidrosis.
The study was divided into two groups: 49 primary hyperhidrosis patients in Group I and 47 age and gender-matched healthy individuals in Group II.
- The average vitamin D and magnesium levels in Group I were statistically significantly lower than in Group II.
- Statistically significant differences were found between the groups in terms of anxiety and depression.
Conclusion: Anxiety and depression are common in patients with primary hyperhidrosis. As shown in this study, both anxiety and depression can be seen with low magnesium levels in patients with primary hyperhidrosis. This could possibly be related to the pathological mechanism involving Vitamin D and magnesium, which determines the common pathway affecting primary hyperhidrosis and anxiety/depression.
Ross syndrome is considered a rare clinical disorder of sweating associated with tonic pupil and muscle disorder. Ross Syndrome, like many syndromes related to “mystery ailments,” and “unknown causes,” is a controversial diagnosis. Medical literature only reports 80 cases worldwide. Yet we get many emails and phone calls describing these very symptoms.
An April 2019 paper offers advice to doctors who are looking for diagnostic answers when a person walks into their office with problems of excessive sweating. The paper appears in the Journal of Family Medicine and Primary Care. (15)
“Ross syndrome is diagnosed by the presence of the characteristic triad of segmental anhidrosis (the inability to sweat normally), depressed deep tendon reflex (your muscle’s inability to stretch), and tonic pupils. It is a rare, misdiagnosed autonomic disorder with less than 80 cases reported in the world literature.”
What is interesting in this study, is that as rare a condition is, this medical paper was able to cite two cases. This gives us a clue that this problem is more common than thought. It is not a challenge of understanding the patient’s symptoms, the symptoms are obvious on examination. The supposed rareness of the problem is the inability to accurately diagnose it.
The patients were treated symptomatically with incomplete relief
Here are the two studies:
“Both cases (aged 35 and 58) presented with complaints of decreased sweating over one half of the face and ipsilateral (one-sided) upper limb and trunk and (other-side) contralateral lower limb. There was compensatory increased sweating and hyperpigmentation (changes in skin color) over the remaining parts of the body.
The duration of symptoms was 2 years and 15 days. The patients had variegated skin color as per the above distribution and hyporeflexia (non or less-responsive muscles) in their lower limbs. One patient also had Holmes-Adie pupil ( larger than normal pupil that responds poorly or slowly to light stimulation). The iodine test showed hypohidrosis in the described areas, which was confirmed by skin biopsy in both cases. The patients were treated symptomatically with incomplete relief. “
How were these two patients treated? What made treatment unsuccessful?
“The treatment of this unpredictable disorder is very important though largely unsatisfactory because compensatory hyperhidrosis (sweating disorder) may lead to heat exhaustion and heatstroke. Systemic anticholinergic drugs (parasympathetic nervous system blockers such as propantheline bromide, glycopyrrolate, oxybutynin, and benztropine) and anxiolytics (beta-blockers, amitriptyline, and fluoxetine) are tried though anticholinergic adverse effects may limit their use.
Topical medications (0.5% glycopyrrolate aqueous cream) and local instillation of botulinum toxin may be tried.
Modified iontophoretic devices (electrical stimulation to help administer medication into your body) and thoracic sympathectomy (a surgery where a portion of the sympathetic nerve trunk in the thoracic region is destroyed) for hyperhidrosis have been tried.
Steroids are indicated if autoimmune etiology is evident. However, environmental modification, wearing wet clothes during physical activity, and other coping strategies remain the mainstay.”
The neurology of Hyperhidrosis
There is a neurological aspect of Hyperhidrosis that is understudied and not well understood. A February 2023 paper in the journal Dermatology and Therapy (16) hyperhidrosis is a central nervous dysfunction characterized by abnormally increased sweating due to a central (nervous system) dysregulation of sweat secretion. . . Physiologically, sweating is a mechanism that regulates body temperature, but it may also be triggered by emotional or gustatory (sense of taste) stimuli. . . The central nervous system controls sweat secretion through the release of neurotransmitters into the autonomous nervous system (ANS) that activate the sweat glands. The hypothalamus has two separate neuronal pathways, one for thermoregulation and one for emotions. Hyperhidrosis may thus be due to either a neuronal dysfunction of ANS regulation leading to a hyperactivity of the sympathetic nervous system, or to abnormal central processing of emotions. Crucially, there is no dysfunction of the sweat glands themselves.”
In the next section, I am going to present one possible explanation of unexplainable and non-responsive hyperhidrosis. Cervical spine instability causes neurologic-like problems including hyperhidrosis.
But what happens when sweating cannot be controlled? For these people, should we look at their necks?
I have had the tests, no one knows what is causing the sweating. I am extremely sensitive to heat. If I feel the least bit hot, I sweat profusely. Sometimes I get a burning sensation on my toes, hands, chest, and eventually all over my body that last anywhere from 30 seconds to a minute or until the body temperature goes down.
Self-manipulation of the neck was the possible cause of the sweating.
This person became a patient of ours. In a further assessment of his clinical condition, we found that he self-adjusted their neck upwards of 50 times a day. The self-adjustment made his neck pain feel better for a while, then the pain would return and he would self-adjust again. This continued throughout the day and as this person says, upwards of 50 times a day. The tension and pain in his neck not only caused headaches that plagued him, but he also had issues with vision and light sensitivity.
- We suspected that this person had Ross syndrome based on sweating, heat intolerance, and chronically dilated pupils.
Sweating caused by cervical disc herniation or cervical spine injury or cervical surgery
Sweating caused by cervical disc herniation is something we see in patients. Yet for many, this is a controversial issue. Controversial means that there is not enough published research to make an opinion one way or the other. For people who have Hyperhidrosis, there is no real controversy. They have it, and if you are like many, you are reading this article because you suffer from many symptoms that your doctors cannot help, the controversy rests in the inability to be treated.
Compensatory hyperhidrosis and endoscopic thoracic sympathectomy
For some of you reading this article, you may have developed sweating problems because of degenerative disc disease in the cervical spine, syndromes such as Ehlers-Danlos Syndrome, and thoracic disease – please see our article Neurogenic and Nonspecific-type thoracic outlet syndrome – Diagnosis and treatment, a whiplash injury suffered in a car accident, or cervical spine surgery.
Compensatory hyperhidrosis is considered a neuropathy problem. It is a side-effect of endoscopic thoracic sympathectomy. Surgery to correct excessive sweating.
Let’s go to the research:
In October 2020, in the journal Medicine (17) surgeons made these observations and explanations as to the cause and effect of compensatory hyperhidrosis and studied 44 patients to see what treatments may help them.
- Compensatory hyperhidrosis is a debilitating postoperative condition occurring in 30% to 90% of patients with primary hyperhidrosis.
- The most appropriate treatment for compensatory hyperhidrosis remains controversial.
Here are the study’s findings:
- The researchers followed the progress of 44 patients with intractable (difficult to treat) compensatory hyperhidrosis who underwent diffuse sympathectomy surgery.
- Patients were followed up to see if their symptoms had resolved.
- Immediate resolution of compensatory hyperhidrosis was achieved in 81% of patients, as determined at the 1 to 2-week postoperative visit.
- With a median follow-up of 22.7 months, compensatory hyperhidrosis continued to be resolved in 46% of the patients. (The long-term success of the surgery was fading).
Suddenly the patient experiences a worsening sweating problem as the excess sweating has now moved into a new area
Let’s review what is happening here:
- Patients underwent endoscopic thoracic sympathectomy because of excessive sweating.
- Much developed compensatory hyperhidrosis.
- The patient went in because they had excessive armpit, palm, head, and facial sweating, or excessive sweating on a portion of the trunk, (mostly upper chest area). While the sweating in these areas may have been corrected, suddenly the patient experiences a worsening sweating problem as the excess sweating has now moved into a new area, the lower back, the lower trunk for example. This may occur because the body is now unable to sweat in the surgically-treated areas.
- The neuropathy that created the excessive sweating mechanism was not repaired. It was only moved to other parts of the body. The sweat command in many of these people was not fixed, only diverted to other areas.
Compensatory sweating developed in 26 (55.3%) patients (within several weeks up to 6 months).
A July 2021 study titled “Hyperhidrosis: treatment, results, problems” (18) assessed the situations of 166 patients following thoracic bilateral sympathectomy for problems of:
- isolated palmar hyperhidrosis which was observed in 46 patients,
- axillary (armpit) hyperhidrosis in 46 patients
- palmar and axillary hyperhidrosis in 74 cases.
Results of surgery:
- Symptoms of hyperhidrosis disappeared early after surgery in all cases.
- Long-term results were followed in 47 patients. Persistent positive effects and patient satisfaction with postoperative outcomes were noted in 44 (93.6%) cases.
- Recurrences occurred in 2 patients with palmar hyperhidrosis and 1 patient with axillary hyperhidrosis for the period from 2 weeks to 6 months.
- Compensatory sweating developed in 26 (55.3%) patients (within several weeks up to 6 months).
- Mild compensatory sweating occurred in 17 patients, moderate – 8 patients, and severe – 1 patient.
- Compensatory sweating was more common in patients with axillary and palmar-axillary hyperhidrosis compared to those with isolated palmar hyperhidrosis.
The surgery is effective but the evidence for that is low
A December 2021 study in the journal Annals of Medicine (19) evaluated the effectiveness and safety of video-assisted thoracoscopic sympathectomy for treating primary axillary hyperhidrosis. The researchers here found that the surgery is a viable and safe option for the treatment of primary axillary hyperhidrosis. “However, the estimation of the effect is quite uncertain because the quality of evidence was extremely low.”
What this study team did was review previously published research on thoracoscopic sympathectomy and combine the outcome data. What they found was the surgery helped, but they were uncertain how much it really helped patients’ quality of life.
I sweat on one side, I do not sweat on the other
We are going to look at a case history study. Many of the symptoms reported by these doctors are similar to those we see in our patients. This demonstrates an awareness of doctors to problems we have seen in nearly three decades of helping people with mysterious, rare, or difficult-to-treat diagnoses.
In these case histories published in the journal Functional Neurology (20), doctors helped show many of the challenges we have observed in patients. That is how delicate the cervical spinal nerves and the sweating mechanism are. In 5 case histories, researchers showed that Hyperhidrosis and anhidrosis, the inability to sweat, coexist side by side. In some people, they have Hyperhidrosis on one side of the face and anhidrosis on the other side of the face. Hyperhidrosis on one side of the trunk and anhidrosis on the other side of the trunk.
If you are reading this article, it is very likely that you may have one side of your face feel hot, clammy, and sweaty, and the other side of your face cool to the touch.
July 2022: Topical and systemic agents, and botulinum toxins, do not seem to work that well
A July 2022 study in the journal Expert Opinion on Pharmacotherapy (21) writes: “Idiopathic hyperhidrosis, regardless of the site of involvement, remains a functional disorder that places a significant burden on patients. After balancing efficacy against adverse events, systemic therapy, although off-label for all forms of hyperhidrosis, can be an added therapeutic option for patients with insufficient response to topical treatment. Until the pathophysiological mechanisms underlying hyperhidrosis are clear (what is really causing it) and the etiological therapeutic approach becomes realistic (addressing what is the true cause), the greatest challenge in the therapeutic management of hyperhidrosis patients seems to be the search for the most convenient combination between different therapeutic modalities (topical and systemic agents, and botulinum toxins) to achieve long-term control of the disease symptoms.
A July 2022 paper in the American Journal of Clinical Dermatology (22) updates treatment opinions in this way: “Severe cases of hyperhidrosis can also increase the risk of developing psychiatric and somatic comorbidities. Conventional non-surgical treatments of hyperhidrosis include aluminum salts, iontophoresis, botulinum toxin injections, and oral glycopyrronium. In recent years, new topical anticholinergic medications and devices have emerged that may improve the patient’s symptoms and even prevent the development of comorbidities. The treatment of hyperhidrosis can be a complex matter and may require the combination of several therapies.”
Non-surgical conservative care treatment surrounding the cervical spine
The treatment these patients received was:
- physical therapy,
- neck traction,
- a neck collar for decompression and pharmacotherapy, consisting of methylcobalamin (vitamin B12), tocopherol nicotinate (vitamin E), and limaprost alfadex (prostaglandin E1).
- Please see our article Cervical Collars – why do they help some people and not others?
Case 1: A 63-year-old man with a three-month history of excessive right facial sweating.
- A year earlier, the man had sustained right 9th and 10th rib fractures and experienced profuse sweating on his left trunk, and subsequently sweating and hotness on the right side of his face and head.
- Neck MRI revealed intervertebral disc bulging at C3–4 and C6–7; compressing the right ventral side of the cervical cord slightly.
- Following the administration of the treatment, his left facial anhidrosis (inability to sweat) was slightly improved, however, the hypohidrosis (inability to sweat) on his right trunk remained although some patchy sweating appeared.
Case 2: A 44-year-old woman with a three-year history of excessive sweating and warm sensation in her face when playing tennis, regardless of the season.
- Her right face, arm, chest, and abdomen showed profuse sweating. Thermography showed increased skin temperature in the hypo/anhidrotic areas (the areas previously where there was no sweating were heating up). MRI study revealed cervical disc herniation at C6–7. As a result of the treatment, her hemifacial anhidrosis improved, and bilateral sweating appeared, extending to her anterior chest and upper back.
- Here is the symptoms of one side improved, one side worsened.
A brief note on one side to the other side of body temperature dysfunction
In the case above, the woman’s body started to heat up in the area where she had a problem previously of the inability to sweat.
Checking the temperature at various points of the body.
- Using an infrared temperature detector, on each side of the body, can be an effective diagnostic way to find out what may be causing the skin sensation abnormalities and development of excessive or inability to sweat problems we are discussing.
Patient demonstration at 1:45 – the clue that temperature dysfunction is being caused by cervical spine instability.
- In the case of the patient in the video, we see that the temperatures we recorded on the left side of the patient are much lower than the temperatures we recorded on the right side of the patient.
- So here we have a clue that the patient’s problems are being caused by something going on in the upper cervical spine. What is the clue? Because in this patient the temperature dysfunction is impacting the entire body. If the problem was confined to the lower body, we would suspect that the problems could be coming either from the neck or the low back.
- In this patient, we suspect that something is irritating the left side of the upper cervical spine or maybe the lower brain stem. It is possibly a problem that has gone on for some time because this type of temperature ranges from one side to the other and typically occurs over a period of time as the nerves get irritated. The more irritation long-term, the worse the problem as temperature regulation is compromised.
Why just one side? Why is it difficult to understand or diagnose?
- We would typically encourage people to check their temperatures at various points on one side of the body against the other side to look for variations. This could help the person and even their health care providers understand that the underlying problem is one coming from the upper cervical spine.
Back to the case histories
These case histories were published in the journal Functional Neurology. Remember that the patients here were treated at a center specializing in researching physical therapy and physiology.
The treatment these patients received was:
- physical therapy,
- neck traction,
- a neck collar for decompression and pharmacotherapy, consisting of methylcobalamin (vitamin B12), tocopherol nicotinate (vitamin E), and limaprost alfadex (prostaglandin E1).
Case 3: A 74-year-old woman with a three-month history of profuse facial sweating, which she experienced during heat exposure and exercise.
- The patient had anhidrosis affecting the left side of the head, face, neck, and shoulder to the ring finger (C7 area), and crossed hypohidrosis at the right abdomen.
- Thermography showed high skin temperature in the anhidrotic and hypohidrosis areas, i.e. the left side of the face to the C7 area and the right side of the abdomen.
- Neck MRI revealed disc herniation, with bulging most pronounced at 3 mm at the C5–6 level
- Following treatment, patchy, spot-like sweating appeared on her left forehead, cheek, and anterior neck, while her hemifacial hyperhidrosis was slightly improved. No further changes were observed in the trunk area.
Again here, the area that had sweating problems started to heat up when the other areas, where excessive sweating was occurring were being treated.
Case 4: A 37-year-old woman presented with profuse sweating affecting the left side of her face and extending to the upper half of her body.
- This patient had profuse sweating on the left face, neck, shoulder, and arm to the C6 area of the left forearm and the palm. Left-sided anhidrosis was observed below this level (i.e. from C7 to T12), in the arm to trunk. Hypohidrosis was observed on the right side at the same level as the hyperhidrosis area, and the patient exhibited crossed anhidrosis, i.e. anhidrosis of the right face, neck, shoulder, and arm to the C6 area of the right forearm and the palm, and anhidrosis from the left C7 to T12 areas in the arm and trunk.
- Thermography showed high skin temperature in the anhidrotic and hypohidrotic areas. Neck MRI revealed cervical disc bulging most pronounced at 3 mm at C5–6 in the sagittal view, and mild compression of the dural sac from the lateral side was observed.
- With the treatment, her right hemifacial anhidrosis improved, and her sweating gradually evolved into a patchy, spot-like sweating pattern. However, the anhidrosis on her trunk bilaterally has not improved in spite of the treatment.
Case 5: A 41-year-old man had suffered from massive sweating since his high school days.
- The patient complained that for the previous four months, the sweating, on exposure to the sun, exercise, or other stimulation, had been more intense on the left side of the face and chest and the right side of the dorsum manus (the back of the hand) than on other skin surfaces.
- Neither anisocoria (pupil disruptions such as we spoke about above in regard to Ross Syndrome, nor blepharoptosis (eyelid droop) was observed.
- The normal endocrinological function was observed
- The patient had dominant sweating in the left frontal, neck, shoulder, upper chest, and low back areas. Sweating at the forearms and palms was slightly more marked on the left side, but the legs showed anhidrosis.
- Thermography showed increased skin temperature on the right side of the whole body. Neck MRI revealed intervertebral disc herniation at C5–6, compressing the dural sac near the midline.
- Treatment was started and his facial sweating became symmetrical, with the restoration of a normal sweating pattern.
The treatment of cervical spine instability at the Hauser Neck Center – Research on cervical instability and Prolotherapy
In the above article, we suggest that many of the problems related to sweating can be treated by addressing cervical spine instability in the neck. There are many ways to treat this problem. Our preferred choice is regenerative medicine injections that begin with Prolotherapy.
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Our research documents our experience with our patients.
In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (23) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.
Further reading: Cervical Spine Realignment and restoring loss of cervical lordosis
In our article Cervical Spine Realignment and restoring loss of cervical lordosis, Dr. Hauser presents the case that cervical spine, upper cervical spine, and lower cervical spine instability may be an unexplored cause of your neurologic-like, vascular-like and psychiatric-like conditions, and symptoms. It is very likely that you are reading this article as a continuation of your research into your symptoms and conditions and you came here from other pages on this website or that you landed here because a doctor, in many cases a chiropractor, mentioned to you that you have C1-C2 instability or C3-C7 instability. That this cervical instability has caused you to lose the natural curve or LORDOSIS in your neck. Further, you have started to come to terms with the understanding that all the tests that you have had performed by neurologists and cardiologists and the prescriptions offered to you by psychiatrists have never offered a “grand unifying theory” or help in diagnosing what was really wrong with you.
Further reading: Symptoms and Conditions of Craniocervical Instability
In this article, Symptoms, and Conditions of Craniocervical Instability, Dr. Hauser has put together a summary of some of the symptoms and conditions that we have seen in our patients either previously diagnosed or recently diagnosed with Craniocervical Instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain.
For many of these people, symptoms, and conditions extended far beyond the neck pain, radiating pain of cervical radiculopathy, headaches, TMJ, and possibly dizziness usually associated with problems in the neck. These people’s symptoms and conditions extend into neurologic-type problems that may include digestion, irregular cardiovascular problems, hallucinogenic sensations, vision problems, hearing problems, swallowing problems, excessive sweating, and a myriad of others.
I want to point out that the symptoms and conditions you will see described below can be caused by many problems. This article demonstrates that craniocervical instability and cervical neck instability can be one of them.
Treating Cervical Spine Instability is treating the symptoms of sweating and coexisting problems
In this video, DMX imaging displays Prolotherapy results in before and after treatment images. This patient’s treatment had problems of a pinched nerve in the cervical spine resolved.
This video demonstrates the alleviation of cervical disc herniation and the patient’s related symptoms.
- In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and the accompanying symptoms of cervical radiculopathy.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
- At 0:34 DMX three months later after this patient had received two Prolotherapy treatments
- At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina are now opening normally during motion
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and that it helped answer many of the questions you may have surrounding Excessive Sweating and Hyperhidrosis. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
References for this article:
1 Henning MA, Ibler KS, Loft I, Ostrowski SR, Erikstrup C, Nielsen KR, Bruun MT, Ullum H, Didriksen M, Dinh KM, Pedersen OB. The health-related quality of life in hyperhidrosis and co-morbidities. Quality of Life Research. 2022 Feb 22:1-0. [Google Scholar]
2 Henning MA, Reguant R, Jørgensen IF, Andersen RK, Ibler KS, Pedersen OB, Jemec GB, Brunak S. The temporal association of hyperhidrosis and its comorbidities–a nationwide hospital‐based cohort study. Journal of the European Academy of Dermatology and Venereology. 2022 Dec;36(12):2504-11. [Google Scholar]
3 Heikkinen SL, Niskala J, Jokelainen J, Tasanen K, Huilaja L, Sinikumpu SP. Hyperhidrosis Comorbidities and Treatments: A Register-based Study among 511 Subjects. Acta Dermato-venereologica. 2022 Jan 28. [Google Scholar]
4 Campanati A, Gregoriou S, Kontochristopoulos G, Offidani A. Oxybutynin for the treatment of primary hyperhidrosis: current state of the art. Skin Appendage Disorders. 2015;1(1):6-13. [Google Scholar]
5 del Boz Gonzalez J, Rodríguez Barón D, Millán‐Cayetano JF, de Troya Martin M. Tolerance of oral oxybutynin in the treatment of hyperhidrosis. Dermatologic therapy. 2020 Aug 14:e14197. [Google Scholar]
6 Del Boz J, García‐Souto F, Rivas‐Ruiz F, Polo‐Padillo J. Survival study of treatment adherence by patients given oral glycopyrrolate for hyperhidrosis following treatment failure with oral oxybutynin. Dermatologic therapy. 2020 Aug 21:e14210. [Google Scholar]
7 Kristensen JK, Nielsen C. Progress and lack of progress in hyperhidrosis research 2015–2020. A concise systematic review. International journal of dermatology. 2022 Feb;61(2):148-57. [Google Scholar]
8 Lee AC, Ferguson MK. Knowledge of surgical management of hyperhidrosis among primary care physicians and the general public. Interactive cardiovascular and thoracic surgery. 2022 Jan 7. [Google Scholar]
9 Zhang D, Zhuang W, Lan Z, Huang S, Gao Z, Chen Q, Ben X, Tang J, Zhou H, Xie L, Qiao G. Long-term follow-up in quality of life before and after endoscopic thoracic sympathicotomy in 367 patients with palmar hyperhidrosis. Annals of palliative medicine. 2022 Jan 10. [Google Scholar]
10 Raveglia F, Orlandi R, Guttadauro A, Cioffi U, Cardillo G, Cioffi G, Scarci M. How to Prevent, Reduce, and Treat Severe Post Sympathetic Chain Compensatory Hyperhidrosis: 2021 State of the Art. Frontiers in surgery. 2021;8. [Google Scholar]
11 Lynch OE, Aherne T, Gibbons J, Boland MR, Ryan ÉJ, Boyle E, Egan B, Tierney S. Five-year follow-up of patients treated with intra-dermal botulinum toxin for axillary hyperhidrosis. Irish Journal of Medical Science (1971-). 2020 Jan 3:1-4. [Google Scholar]
12 Park JH, Kim R, Na SH, Kwon SY. Effect of botulinum toxin in stellate ganglion for craniofacial hyperhidrosis: a case report. Journal of International Medical Research. 2021 Mar;49(3):03000605211004213. [Google Scholar]
13 Lowe N, Naumann M, Eadie N. Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine. 2023 Jul 7;102(Suppl). [Google Scholar]
14 Manav V, Türk CB, Kara Polat A, Erdil D, Baş S, Koku Aksu AE. Evaluation of the serum magnesium and vitamin D levels and the risk of anxiety in primary hyperhidrosis. Journal of cosmetic dermatology. 2022 Jan;21(1):373-9. [Google Scholar]
15 Panda S, Verma D, Budania A, Bharti JN, Sharma RK. Clinical and laboratory correlates of selective autonomic dysfunction due to Ross syndrome. Journal of Family Medicine and Primary Care. 2019 Apr;8(4):1500. [Google Scholar]
16 Wohlrab J, Bechara FG, Schick C, Naumann M. Hyperhidrosis: A central nervous dysfunction of sweat secretion. Dermatology and Therapy. 2023 Feb;13(2):453-63. [Google Scholar]
17 Moon MH, Hyun K, Park JK, Lee J. Surgical treatment of compensatory hyperhidrosis: Retrospective observational study. Medicine. 2020 Oct 16;99(42). [Google Scholar]
18 Motus IY, Bazhenov AV. Gipergidroz: lechenie, rezul’taty, problemy [Hyperhidrosis: treatment, results, problems]. Khirurgiia (Mosk). 2021;(7):12-17. Russian. doi: 10.17116/hirurgia202107112. PMID: 34270188.
19 Felisberto Jr G, Maria Cataneo AJ, Cristina Cataneo D. Thoracic sympathectomy for the treatment of primary axillary hyperhidrosis: systematic review and proportional meta-analysis. Annals of medicine. 2021 Jan 1;53(1):1216-26. [Google Scholar]
20 Iwase S, Inukai Y, Nishimura N, Sato M, Sugenoya J. Hemifacial hyperhidrosis associated with ipsilateral/contralateral cervical disc herniation myelopathy. Functional considerations on how compression pattern determines the laterality. Functional neurology. 2014 Jan;29(1):67. [Google Scholar]
21 Campanati A, Gregoriou S, Milia-Argyti A, Kontochristopoulos G, Radi G, Diotallevi F, Martina E, Offidani A. THE PHARMACOLOGICAL TREATMENT AND MANAGEMENT OF HYPERHIDROSIS. Expert Opinion on Pharmacotherapy. 2022 Jun 3(just-accepted). [Google Scholar]
22 Henning MA, Bouazzi D, Jemec GB. Treatment of Hyperhidrosis: An Update. American Journal of Clinical Dermatology. 2022 Jul 1. [Google Scholar]
23 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
This article was updated August 1, 2023