Excessive Sweating – Hyperhidrosis. Is 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 the unknown reasons the following possible causes were ruled out by various testings.
- Tests for:
- Hormone disorders
- Thyroid problems
- Infectious disease
- and menopausal problems, NOTHING comes back positive, so what can it be?
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 the people want to be treated, is the problem of excess sweating.
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, 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.
The 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. The 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, burning sensation in the face, neck, and upper torso. I am on a lot of medications. For the 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, 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,(1) 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.(2)
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, the 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 publishing in the August 2020 issue of the journal Dermatologic therapy (3), 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), average age 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 the people, perhaps like yourself, who continue to have problems of excessive sweating following these medications.
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 (4) 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 treatments.
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.(5)
“Ross syndrome is diagnosed by the presence of the characteristic triad of segmental anhidrosis (the inability to sweat normally), depressed deep tendon reflex (your muscles 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 complaint 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 lower limbs. One patient also had Holmes-Adie pupil ( larger than normal pupil that responds poorly or slowly to light stimulation). 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.”
This paper made no mention of cervical spine disorders.
In this video, Ross Hauser, MD, and Brian Hutcheson, DC discuss symptoms of abnormal sweating and temperature regulation over half of their body or certain areas that are hot or cold compared to the rest of the body as well as specific areas that are hypersensitive or numb compared to the rest of the body, and other odd skin sensations, including localized swelling, vibration, and severe itching that have not been resolved by other traditional treatments by a dermatologist, rheumatologist, neurologist, etc.
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 the 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, 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, 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 a 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 (6) surgeons made these observations and explanations as to 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 is the study’s findings:
- The researchers followed the progress of 44 patients with intractable (difficult to treat) compensatory hyperhidrosis who underwent diffuse sympathicotomy 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.
- Many 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.
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 (7), doctors helped show many of the challenges we have observed in patients. That is how delicate the cervical spinal nerves and the sweating mechanism is. 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.
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 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 was 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 as the symptoms of one side improved, one side worsened.
A brief note on one-side to the other side body temperature dysfunction
In the case above, the woman’s body started to heat up in the area where she had a problem previous of inability to sweat. In the video above at the 1:15 mark, Dr. Hauser and Dr. Hutcheson discuss temperature abnormalities from one side to the other. The learning points are:
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 sometime because these type of temperature ranges from one side to the other typically occur 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
In these case histories 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 on heat exposure and exercise.
- 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 hypohidrotic 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 at 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 hyperhidrotic 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 anhidroisis 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 (eye lid droop) was observed.
- Normal endocrinological function was observed
- Patient had dominant sweating in the left frontal, neck, shoulder, upper chest, and low back areas. Sweating at 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 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.(8) 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.
This is what we wrote in this paper: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs (such as excessive sweating or inability to sweat and temperature dysregulation) or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of cervicogenic dysphagia type symptoms, cervical instability.
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 accompanying symptoms of cervical radiculopathy.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals a 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 is now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina is now opening normally during motion
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