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Hyperhidrosis
Keith D. Mortman, MD, FACS, FCCP discusses hyperhidrosis. He highlights the types of hyperhidrosis, at what age it tends to present with symptoms and the latest advances in treatment options at The George Washington University Hospital.
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Learn more about Keith D. Mortman, MD, FACS, FCCP
Keith D. Mortman, MD, FACS, FCCP
Keith Mortman, MD, FACS, FCCP is board-certified in Thoracic Surgery. He is the Director of Thoracic Surgery and an Associate Professor of Surgery with The George Washington University School of Medicine & Health Sciences.Learn more about Keith D. Mortman, MD, FACS, FCCP
Transcription:
Melanie Cole (Host): Welcome to GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. And joining me to highlight hyperhidrosis is Dr. Keith Mortman. He's an Associate Professor of Surgery and Chief in the Division of Thoracic Surgery at the George Washington University School of Medicine & Health Sciences, and he's affiliated with The George Washington University Hospital. Dr. Mortman, it's a pleasure to have you join us today. I'd like you to start for other providers. Tell us a little bit about hyperhidrosis, the prevalence, what you see in the trends.
Dr. Keith Mortman: So hyperhidrosis is a condition where patients sweat more than they need to to control their body's temperature. And we like to start by classifying it two different ways. One is primary hyperhidrosis and those are patients that I can treat with a procedure. And these tend to be younger patients. Usually, they come to medical attention from their teenage years to their early 40s and where the sweating appears in focal areas, most commonly the palms, but we can also see it on the soles of the feet as well as under the arms and, rarely, sometimes facial sweating. And we differentiate this from secondary hyperhidrosis where patients sweat from some other underlying medical condition. And those can be endocrine disorders such as thyroid conditions. It could be related to menopause or cancer or side effect from medications. And in those patients, you really have to treat the underlying medical problem. So we don't really have a surgical treatment for those patients with secondary hyperhidrosis. This does tend to be an underrecognized and underdiagnosed condition. We believe it affects anywhere from 1% to 3% of the general population.
Melanie Cole (Host): Well, thank you for that comprehensive explanation, Dr. Mortman. So when you're speaking about the clinical presentation and you mentioned secondary and primary and secondary, meaning those metabolic disorders or illnesses, medications, all the things you discussed, why is age important when you are determining what the cause is? And why is it important if it presents in the later stages or the later ages of the patients?
Dr. Keith Mortman: Well, I think it's important to recognize the condition early on, just because, for no other reason, the very severe psychological, social and professional implications this condition can have on these younger patients, who again tend to present in their teenage and 20s. So over the past 20 some odd years, I've seen these patients who may alter what career they go into because of the excessive hand or underarm sweating, people who have steered away from business fields because of the hand shaking that's required. I've seen teenagers who never learned how to drive because their hands will literally slip on the steering wheel, teenagers who never went to their senior prom because they were embarrassed about that. And sometimes the sweating can be so severe where people need to change their undergarments several times a day, where they might have three, four or five different t-shirts that they change into because of the underarm sweating can be so bad or the hand sweating can be so severe and they constantly rub their hands on their pants, and it gets to be so bad they can actually ruin their clothing; people who have literally sweated through their shoes, and need to change footwear a couple times during the day. So although it's not cancer, it is certainly more than just a simple benign condition, it can have very profound effects on these younger patients.
Melanie Cole (Host): Thank you for pointing out those psychosocial aspects of this condition. So speak about some of the current issues and medical or surgical management. I'd like you to start with the non-surgical some of the new medications available and how you take into account the quality of life of the patient.
Dr. Keith Mortman: Yeah. So a lot of this starts with really the patient's history and their presentation. The ones who I tend to see in my clinic have tried at least one surgical treatment for a period of time. And when the sweating is bad enough, invariably these nonsurgical treatments tend to not work very well for these patients.
Typically, they'll start with prescription-strength antiperspirants that could be used for these different focal areas of the body. Botox has been used for many, many years for these different conditions with variable success rates. The problem with the Botox is that it tends to not be very comfortable to get many, many needles placed into your palms or into your axilla. Many insurance companies do not cover Botox treatment. It can work for the condition. However, it's not a permanent fix. It's temporary, usually lasting only several months. And then, the treatment needs to be repeated.
There is another treatment called iontophoresis and that's essentially a low level electric current bath that the patients will put their palms or their feet into and this can be an expensive equipment to buy. I'm told it's not the most comfortable sensation when you do that. It usually requires daily treatment, usually around an hour at a time. And as soon as the treatment is stopped, the condition recurs, the sweating comes back.
So when I see these patients in my clinic that have tried these various nonsurgical treatments, we do talk about a surgical intervention, which is what I do, and that is a procedure called a thoracoscopic sympathectomy. I specialize in minimally invasive surgery and this is probably the most minimally invasive operation that I do. it is done under general anesthesia. The entire procedure takes roughly 25 minutes where we use essentially a two-millimeter scope to look into the chest. We identify the sympathetic nerve, which is responsible for this condition. This is essentially caused by an overexcitation of that nerve, which sends the signals to the sweat glands. The nerve lives in a very constant location in the chest so that we identify it. We usually divide the nerve at the level of the third and fourth ribs on one side and then repeat the other side. As I said, the entire procedure takes about 25 minutes. Patients are observed briefly in the recovery room, and then they go home. So this is an outpatient procedure. It is covered by almost every major insurance company and the results are extremely gratifying for the patients.
Melanie Cole (Host): And how have been your outcomes? Because this is not something that every surgeon around the country is doing the, CTS. So tell us a little bit about your outcomes and what really makes it unique, why you're doing what you're doing.
Dr. Keith Mortman: Yeah. So the outcomes, again, tend to be very good for this condition and, specifically ,for the palmar hyperhidrosis, those patients tend to have the best outcomes. As we know, there are a few things in medicine and surgery that are a hundred percent guaranteed, but for palmar hyperhidrosis, this is the closest that we can come to that. And what I mean is that approximately 99 plus percent of patients with hand sweating specifically will have complete resolution of their hand sweating. And some of the greatest benefits to this are that the results are immediate. And they're permanent, so that patients will wake up in the recovery room with dry hands. This is a one and done. So this is not something that needs to be repeated a couple of months later or a year or two later. When we talk about the other areas such as the axillary sweating and the plantar sweating, those results are very good. They're just not quite 99%. I usually tell my patients that approximately 80% of patients will see either significant improvement or resolution of the sweating into those areas.
Melanie Cole (Host): Wow. That's quite effective. So since it can be exacerbated in the warmer months, and we've talked about the treatment options out there. I'd like you to speak to other professionals that may be seeing this condition as to how to work on that psychosocial aspect, because as you said, it could cause emotional distress, occupational disability. So what is your advice to them when they are working with these patients that maybe have not undergone the surgery yet and are still in those medicational interventions and other interventions at that point? What would you like them to know about working with those patients?
Dr. Keith Mortman: Yeah, I think the first thing for the primary care provider specifically is to recognize the condition because, like I said, it's typically underdiagnosed. These tend to be patients who shy away from shaking hands, although, you know, now in the era of COVID, many of us do that as well. But these patients who, again, may come in with sweat stains on their clothing, on their shirts and their pants. So I think it's something to inquire about particularly during those teenage years through the thirties. I do think it is appropriate to try nonsurgical treatment first, to give that a certain period of time, perhaps several months. For patients who do present with a more mild form of the sweating, those nonsurgical treatments very well might be effective for them. But again, what I've seen over the past 20 years is for patients who have very severe forms of the sweating, these nonsurgical treatments tend to not be very effective for them.
Melanie Cole (Host): And as we wrap up, please speak about the unique areas that set you apart. Why it's important to refer to the specialists at the George Washington University Hospital? And if someone wants to refer a patient for hyperhidrosis, whether it's primary or secondary, when is the best time to do that?
Dr. Keith Mortman: So this is one of the procedures that we do specialize in the division of thoracic surgery at GW Hospital. So, we take great care in working with these patients, and their providers and the referring physicians. We do specialize specifically in minimally invasive thoracic surgery. We have had, great outcomes over the past nine years that we've been doing this at GW specifically. So I think for the primary care physicians who might be listening to this podcast, when you have one of these younger patients with primary hyperhidrosis again, which tends to occur in these focal areas that we've been talking about, I do think it's valid to try non-surgical treatment first. But if you find over several months that that is not working, we are happy to evaluate these patients. And as I started the conversation, we do differentiate these patients from secondary hyperhidrosis patients, because the surgical treatment for this is not effective for the secondary hyperhidrosis patients.
Melanie Cole (Host): Thank you so much, Dr. Mortman, for joining us today and sharing your incredible expertise in this area. And to refer your patient, please call 1-888-4GW-DOCS. Or if you have a question for one of our specialists, you can email This email address is being protected from spambots. You need JavaScript enabled to view it.. That concludes this episode of GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole.
Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.
Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.
Melanie Cole (Host): Welcome to GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. And joining me to highlight hyperhidrosis is Dr. Keith Mortman. He's an Associate Professor of Surgery and Chief in the Division of Thoracic Surgery at the George Washington University School of Medicine & Health Sciences, and he's affiliated with The George Washington University Hospital. Dr. Mortman, it's a pleasure to have you join us today. I'd like you to start for other providers. Tell us a little bit about hyperhidrosis, the prevalence, what you see in the trends.
Dr. Keith Mortman: So hyperhidrosis is a condition where patients sweat more than they need to to control their body's temperature. And we like to start by classifying it two different ways. One is primary hyperhidrosis and those are patients that I can treat with a procedure. And these tend to be younger patients. Usually, they come to medical attention from their teenage years to their early 40s and where the sweating appears in focal areas, most commonly the palms, but we can also see it on the soles of the feet as well as under the arms and, rarely, sometimes facial sweating. And we differentiate this from secondary hyperhidrosis where patients sweat from some other underlying medical condition. And those can be endocrine disorders such as thyroid conditions. It could be related to menopause or cancer or side effect from medications. And in those patients, you really have to treat the underlying medical problem. So we don't really have a surgical treatment for those patients with secondary hyperhidrosis. This does tend to be an underrecognized and underdiagnosed condition. We believe it affects anywhere from 1% to 3% of the general population.
Melanie Cole (Host): Well, thank you for that comprehensive explanation, Dr. Mortman. So when you're speaking about the clinical presentation and you mentioned secondary and primary and secondary, meaning those metabolic disorders or illnesses, medications, all the things you discussed, why is age important when you are determining what the cause is? And why is it important if it presents in the later stages or the later ages of the patients?
Dr. Keith Mortman: Well, I think it's important to recognize the condition early on, just because, for no other reason, the very severe psychological, social and professional implications this condition can have on these younger patients, who again tend to present in their teenage and 20s. So over the past 20 some odd years, I've seen these patients who may alter what career they go into because of the excessive hand or underarm sweating, people who have steered away from business fields because of the hand shaking that's required. I've seen teenagers who never learned how to drive because their hands will literally slip on the steering wheel, teenagers who never went to their senior prom because they were embarrassed about that. And sometimes the sweating can be so severe where people need to change their undergarments several times a day, where they might have three, four or five different t-shirts that they change into because of the underarm sweating can be so bad or the hand sweating can be so severe and they constantly rub their hands on their pants, and it gets to be so bad they can actually ruin their clothing; people who have literally sweated through their shoes, and need to change footwear a couple times during the day. So although it's not cancer, it is certainly more than just a simple benign condition, it can have very profound effects on these younger patients.
Melanie Cole (Host): Thank you for pointing out those psychosocial aspects of this condition. So speak about some of the current issues and medical or surgical management. I'd like you to start with the non-surgical some of the new medications available and how you take into account the quality of life of the patient.
Dr. Keith Mortman: Yeah. So a lot of this starts with really the patient's history and their presentation. The ones who I tend to see in my clinic have tried at least one surgical treatment for a period of time. And when the sweating is bad enough, invariably these nonsurgical treatments tend to not work very well for these patients.
Typically, they'll start with prescription-strength antiperspirants that could be used for these different focal areas of the body. Botox has been used for many, many years for these different conditions with variable success rates. The problem with the Botox is that it tends to not be very comfortable to get many, many needles placed into your palms or into your axilla. Many insurance companies do not cover Botox treatment. It can work for the condition. However, it's not a permanent fix. It's temporary, usually lasting only several months. And then, the treatment needs to be repeated.
There is another treatment called iontophoresis and that's essentially a low level electric current bath that the patients will put their palms or their feet into and this can be an expensive equipment to buy. I'm told it's not the most comfortable sensation when you do that. It usually requires daily treatment, usually around an hour at a time. And as soon as the treatment is stopped, the condition recurs, the sweating comes back.
So when I see these patients in my clinic that have tried these various nonsurgical treatments, we do talk about a surgical intervention, which is what I do, and that is a procedure called a thoracoscopic sympathectomy. I specialize in minimally invasive surgery and this is probably the most minimally invasive operation that I do. it is done under general anesthesia. The entire procedure takes roughly 25 minutes where we use essentially a two-millimeter scope to look into the chest. We identify the sympathetic nerve, which is responsible for this condition. This is essentially caused by an overexcitation of that nerve, which sends the signals to the sweat glands. The nerve lives in a very constant location in the chest so that we identify it. We usually divide the nerve at the level of the third and fourth ribs on one side and then repeat the other side. As I said, the entire procedure takes about 25 minutes. Patients are observed briefly in the recovery room, and then they go home. So this is an outpatient procedure. It is covered by almost every major insurance company and the results are extremely gratifying for the patients.
Melanie Cole (Host): And how have been your outcomes? Because this is not something that every surgeon around the country is doing the, CTS. So tell us a little bit about your outcomes and what really makes it unique, why you're doing what you're doing.
Dr. Keith Mortman: Yeah. So the outcomes, again, tend to be very good for this condition and, specifically ,for the palmar hyperhidrosis, those patients tend to have the best outcomes. As we know, there are a few things in medicine and surgery that are a hundred percent guaranteed, but for palmar hyperhidrosis, this is the closest that we can come to that. And what I mean is that approximately 99 plus percent of patients with hand sweating specifically will have complete resolution of their hand sweating. And some of the greatest benefits to this are that the results are immediate. And they're permanent, so that patients will wake up in the recovery room with dry hands. This is a one and done. So this is not something that needs to be repeated a couple of months later or a year or two later. When we talk about the other areas such as the axillary sweating and the plantar sweating, those results are very good. They're just not quite 99%. I usually tell my patients that approximately 80% of patients will see either significant improvement or resolution of the sweating into those areas.
Melanie Cole (Host): Wow. That's quite effective. So since it can be exacerbated in the warmer months, and we've talked about the treatment options out there. I'd like you to speak to other professionals that may be seeing this condition as to how to work on that psychosocial aspect, because as you said, it could cause emotional distress, occupational disability. So what is your advice to them when they are working with these patients that maybe have not undergone the surgery yet and are still in those medicational interventions and other interventions at that point? What would you like them to know about working with those patients?
Dr. Keith Mortman: Yeah, I think the first thing for the primary care provider specifically is to recognize the condition because, like I said, it's typically underdiagnosed. These tend to be patients who shy away from shaking hands, although, you know, now in the era of COVID, many of us do that as well. But these patients who, again, may come in with sweat stains on their clothing, on their shirts and their pants. So I think it's something to inquire about particularly during those teenage years through the thirties. I do think it is appropriate to try nonsurgical treatment first, to give that a certain period of time, perhaps several months. For patients who do present with a more mild form of the sweating, those nonsurgical treatments very well might be effective for them. But again, what I've seen over the past 20 years is for patients who have very severe forms of the sweating, these nonsurgical treatments tend to not be very effective for them.
Melanie Cole (Host): And as we wrap up, please speak about the unique areas that set you apart. Why it's important to refer to the specialists at the George Washington University Hospital? And if someone wants to refer a patient for hyperhidrosis, whether it's primary or secondary, when is the best time to do that?
Dr. Keith Mortman: So this is one of the procedures that we do specialize in the division of thoracic surgery at GW Hospital. So, we take great care in working with these patients, and their providers and the referring physicians. We do specialize specifically in minimally invasive thoracic surgery. We have had, great outcomes over the past nine years that we've been doing this at GW specifically. So I think for the primary care physicians who might be listening to this podcast, when you have one of these younger patients with primary hyperhidrosis again, which tends to occur in these focal areas that we've been talking about, I do think it's valid to try non-surgical treatment first. But if you find over several months that that is not working, we are happy to evaluate these patients. And as I started the conversation, we do differentiate these patients from secondary hyperhidrosis patients, because the surgical treatment for this is not effective for the secondary hyperhidrosis patients.
Melanie Cole (Host): Thank you so much, Dr. Mortman, for joining us today and sharing your incredible expertise in this area. And to refer your patient, please call 1-888-4GW-DOCS. Or if you have a question for one of our specialists, you can email This email address is being protected from spambots. You need JavaScript enabled to view it.. That concludes this episode of GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole.
Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.
Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.