SKIN DEEP

A Clinical Case of Primary Hyperhidrosis

Usaima Siddiqi Ahmad, PDTF, OMS IV

Date of Patient Exam: Sep. 1, 2008

Student Year at That Time: OMS III

Supervising Physician: Rebecca Giusti, D.O.

COMP, Western University of Health Sciences

Case

CC: “sweaty hands, armpits, and feet” HPI

A 23 y/o female presents with excessive palmar, axillary, and plantar perspiration that began at age eleven, near the time of menarche.

She states that warm to hot temperatures, stress (emotional or physical), and anxiety exacerbate her condition, while colder temperatures and a full night of sleep are palliative.

Once started, symptoms tend to persist throughout the entire day without relief.

HPI Continued

She has tried prescription strength deodorants, topical solutions, and iontophoresis without relief. She has a prescription for anti-cholinergics, but has not tried them due to feared side effects.

Pt. states she is currently a 6/10 on a “Perspiration” scale that we developed together Perspiration Scale

• 0 = asymptomatic• 5 = “clamminess” in affected areas• 10= “dripping” sweat from affected areas

No associated symptoms noted, per patient

PMH, SxH, Rxs, Allergies, FH

PMH: unremarkable; no falls, trauma, motor vehicle accidents

SxH: unremarkable Medications: none Allergies: NKDA, no environmental allergies FH: Healthy parents. Brother has palmar

hyperhidrosis (much less severe, per pt).

Social History

OMS-I Single, not sexually active No tobacco use, marijuana use, or other

illicit drug use Occasional/social alcohol use Caffeine: One 12 oz. cup per day Psychosocial Stressors

Boundaries• Personal relationships: hand holding• Professional life: hand shaking, stains on clothing

Physical VS, HEENT, CV, Resp, and Abd Exam

Deferred Extremities

Pulses intact bilaterally in UE and LE No clubbing, cyanosis, nor edema noted

Neurological Gait: N CN II- XII grossly intact Sensation: Grossly intact over UE and LE B/L and

trunk DTRs: +2/4 patellar and biceps, bilaterally

Structural Exam, At Initial Visit Head (H)

Increased venous congestion, SBS compression, restricted right OM suture

Cervical Region (C)OA: FRLSR, C3-6 FRRSR

TART changes noted throughout region Thoracic Region (T)

Restricted Supraclavicular fossa, B/LT2-3 NRLSR, T7-9 ERRSR

Initial Structural Exam, Cont

Ribs (R)Right Rib 1: Inh SD, Left Rib 5: Inh SD

Lumbar Region (L)L1-2 FRLSL, L5ERLSL

Hypertonicity in paravertebral mm. B/L Sacral Region (S)

R/L sacral torsion Upper Extremities (UE)

Tenderness during passive ROM of right glenohumeral joint

Assessment

1. SD of the H,C, T, R, L, S, UE 2. Primary Focal Hyperhidrosis

Isolated to the following areas:• Axillary• Palmar• Plantar

As opposed to Secondary or Generalized Hyperhidrosis

Hyperhidrosis Unknown Etiology

? Genetic component• FH is a component in ¼ of patients

Primary vs. Secondary Adolescence vs. Any time in life Craniofacial, axillary, palmar, plantar, full body

0.6-1.0% of population is effected “Occasional” spontaneous regression after age 35 Palmar or plantar keratoderma may occur

Treatment Options and Side Effects

Home Remedies- cornstarch Low efficacy for most

patients OMM

Tx Reaction, rarely permanent

Deodorants (OTC and Prescription) Only effective for axillary

type Skin irritation, low efficacy in

moderate-severe cases Topical Agents (aluminum based)

Skin irritation, low efficacy in moderate-severe cases

Theoretically oncogenic

Anticholinergics Blurry vision, dry mouth, dry

membranes, urinary retention, constipation, anorexia

Iontophoresis Expense, time consuming-

daily, and may cause dermatitis

Botulinum Toxin (BTX-A) Expense, painful, results last

about 4 months Repetitive injections

Endoscopic Transthoracic Sympathectomy (ETS) and Lumbar Sympathectomy Surgical procedure, Horner’s

Syndrome, compensatory hyperhidrosis

Osteopathic Approach to Patient Care

Biomechanical

Address Somatic Dysfunction Recurrent findings on patient

OA and T2-3 somatic dysfunctions, sacral torsion

Regions Addressed

Head:SBS DecompressionVenous Sinus DrainageHVLA to OASuboccipital Release

Cervicals:BLT, ST, MFR

Thoracics and Lumbars:

HVLA, ME, ST, MFR

Pelvis and Sacrum:ME, CrS

Ribs:BLT, HVLA

Neurofascial ReleaseAlso performed during Tx 3-4

Neurological

Balancing the Autonomic Nervous SystemOMT to cervical and sacral areas for

parasympathetic balanceOMT to thoracic, lumbar, and costal regions for

sympathetic balance

Autonomic Control

Sympathetic:Sympathetic: Parasympathetic:

Sympathetic ChainT1-L2

Sacral PlexusS2-S4

Vagus Nerve:exits cranium

near OA

Circulatory/Respiratory and Metabolic

“…Localized segmental insults to the musculoskeletal system… produced rather substantial disturbances in the sympathetic function, at least as reflected in sweat-gland activity and in vascular and circulatory changes.” –I.M. Korr

OMT to transition zones improved C/R functions 1Relieving somatic dysfunction leads to:

Decreased energy demand Decreased energy expenditure 1Buzzell, 1970

Biopsychosocial

Online Support Groups www.thedailystrength.org, www.hyperhidrosis.org, facebook.com

Classmates Decreased severity of condition with treatments

Increased social contact Decreased anxiety in social situations

Pre and Post Tx Outcomes per Week

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4

Visit (Week)

Per

spir

atio

n S

cale

Val

ue

Day

s o

f R

elie

f

Pre-Tx

Post-Tx

Days of Relief

Outcomes

*Data Obtained Sep 2008

Conclusion

Students can make a difference This case illustrates that OMM can

influence autonomic function Structure influences function at many

different levels

References Buzzell, Keith A. “The Cost of Human Posture.” The Physiological Basis of

Osteopathic Medicine. Pg63-72. New York: Post Graduate Institute of Osteopathic Medicine and Surgery,1970. Pg63-72.

Kuchera, William A., and Michael L. Kuchera.”Research and the Osteopathic Concept.” Osteopathic Principles in Practice. 2nd ed. Kirksville, Mo.: Kirksville College of Osteopathic Medicine, 1991. Print. Kuchera and Kuchera.

Korr, Irvin M. The Collected Papers of Irvin M. Korr. Ed. Barbara Peterson. Colorado Springs: American Academy of Osteopathy, 1979. Print.

Korr, Irvin M. "The Segmental Nervous System as a Mediator and Organizer of Disease Processes." The Physiological Basis of Osteopathic Medicine. New York: Postgraduate Institute of Osteopathic Medicine and Surgery, 1970. Print. Pg 73-84.

Fealey Robert D, Sato Kenzo, "Chapter 82. Disorders of the Eccrine Sweat Glands and Sweating.” Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2985825.

Low Phillip A, Engstrom John W, "Chapter 370. Disorders of the Autonomic Nervous System." Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e: www.accessmedicine.com/content.aspx?aID=2906166. http://www.accessmedicine.com/content.aspx?aID=2906166.

Ropper AH, Samuels MA, "Chapter 26. Disorders of the Autonomic Nervous System, Respiration, and Swallowing.” Ropper AH, Samuels MA: Adams and Victor's Principles of Neurology, 9e: http://www.accessmedicine.com/content.aspx?aID=3634223.