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The treatment options for hypohidrosis and anhidrosis is limited. Those with hypohidrosis should avoid drugs that can aggravate the condition (see medication-causes). They should limit activities that raise the core body temperature and if exercises are to be performed, they should be supervised and be performed in a cool, sheltered and well-ventilated environment. In instances where the cause is known, treatment should be directed at the primary pathology. In autoimmune diseases, such as Sjogren syndrome and systemic sclerosis, treatment of the underlying disease using immunosuppressive drugs may lead to improvement in hypohidrosis. In neurological diseases, the primary pathology is often irreversible. In these instances, prevention of further neurological damage, such as good glycaemic control in diabetes, is the cornerstone of management. In acquired generalized anhidrosis, spontaneous remission may be observed in some cases. Numerous cases have been reported to respond effectively to systemic corticosteroids. Although an optimum dose and regime has not been established, pulse methylprednisolone (up to 1000 mg ⁄ day) has been reported to have good effect.
Compensatory hyperhidrosis is a form of neuropathy. It is encountered in patients with myelopathy, thoracic disease, cerebrovascular disease, nerve trauma or after surgeries. The exact mechanism of the phenomenon is poorly understood. It is attributed to the perception in the hypothalamus (brain) that the body temperature is too high. The sweating is induced to reduce body heat.
Excessive sweating due to nervousness, anger, previous trauma or fear is called hyperhidrosis.
Compensatory hyperhidrosis is the most common side effect of endoscopic thoracic sympathectomy, a surgery to treat severe focal hyperhidrosis, often affecting just one part of the body. It may also be called "rebound" or "reflex hyperhidrosis". In a small number of individuals, compensatory hyperhidrosis following sympathectomy is disruptive, because afflicted individuals may have to change sweat-soaked clothing two or three times a day.
According to Dr Hooshmand, sympathectomy permanently damages the temperature regulatory system. The permanent destruction of thermoregulatory function of the sympathetic nervous system causes latent complications, e.g., RSD in contralateral extremity.
Following surgery for axillary (armpit), palmar (palm) hyperhidrosis (see focal hyperhidrosis) and blushing, the body may sweat excessively at untreated areas, most commonly the lower back and trunk, but can be spread over the total body surface below the level of the cut. The upper part of the body, above the sympathetic chain transection, the body becomes anhidriotic, where the patient is unable to sweat or cool down, which further compromises the body's thermoregulation and can lead to elevated core temperature, overheating and hyperthermia. Below the level of the sympathetic chain interruption, body temperature is significantly lower, creating a stark contrast that can be observed on thermal images. The difference in temperatures between the sympathetically under- and overactive regions can be as high as 10 Celsius.
Of people that have a sympathectomy, it is impossible to predict who will end up with a more severe version of this disorder, as there is no link to gender, age or weight. There is no test or screening process that would enable doctors to predict who is more susceptible.
A number of treatments are available. The most successful non-invasive procedure is cognitive behavioural therapy (CBT), which attempts to alleviate the anxiety felt by sufferers.
In extreme cases a surgical procedure known as endoscopic transthoracic sympathicotomy (ETS) is available. Pioneered by surgeons in Sweden, this procedure has recently become increasingly controversial due to its many potential adverse effects. Patients who have undergone the procedure frequently complain of compensatory sweating and fatigue, with around 5% reconsidering getting the treatment. ETS is now normally only considered in extreme cases where other treatments have been ineffective.
Hypohidrosis is diminished sweating in response to appropriate stimuli. While hyperhidrosis is a socially troubling but benign condition, hypohidrosis can lead to hyperthermia, heat exhaustion, heat stroke and potentially death. An extreme case of hypohydrosis in which there is a complete absence of sweating and the skin is dry is termed anhidrosis.
Morphine has been found to be effective in aborting episodes; sometimes it is the only medication that can combat the sympathetic response. Morphine helps lower respiration rates and hypertension. It is given in doses of two milligrams to eight milligrams but can be administered up to twenty milligrams. Nausea and vomiting are common side effects. Withdrawal is sometimes seen in patients.
Clonidine is an alpha receptor agonist that helps reduces sympathetic activity leaving the hypothalamus and reduces circulating catecholamines. It is helpful in lowering blood pressure and heart rate, but it does not show much of an effect on other symptoms. It may also increase sympathetic inhibition in the brainstem. Bromocriptine is a dopamine agonist that helps lower blood pressure. Its effects are modest, but they are not well understood. Baclofen is a GABA agonist that helps control muscle spasms, proving to be helpful in treating dystonia. Benzodiazepines bind to GABA receptors and work as muscle relaxants. Benzodiazepines also combat high blood pressure and respiratory rates; however, they are associated with glaucoma, which is a rather serious side effect. Gabapentin inhibits neurotransmitter release in the dorsal horn of the spinal cord and various areas of the central nervous system. It helps treat mild symptoms and can be tolerated for longer periods of time compared to other drug treatments. Dantrolene helps combat dystonia and fever by affecting muscle contraction and relaxation cycles. It hinders the release of calcium from the sarcoplasmic reticulum, inhibiting muscle contraction. It causes decreases in respiration, but it can be very dangerous for the liver. Again, these treatments are seen case by case and treat symptoms well. They do not treat the syndrome as a whole or preventatively. Efficacy varies patient to patient, as symptoms do.
In most of the reported cases, the treatment options were very similar. Plasmapheresis alone or in combination with steroids, sometimes also with thymectomy and azathioprine, have been the most frequently used therapeutic approach in treating Morvan’s Syndrome. However, this does not always work, as failed response to steroids and to subsequently added plasmapheresis have been reported. Intravenous immunoglobulin was effective in one case.
In one case, the dramatic response to high-dose oral prednisolone together with pulse methylprednisolone with almost complete disappearance of the symptoms within a short period should induce consideration of corticosteroids.
In another case, the subject was treated with haloperidol (6 mg/day) with some improvement in the psychomotor agitation and hallucinations, but even high doses of carbamazepine given to the subject failed to improve the spontaneous muscle activity. Plasma Exchange (PE) was initiated, and after the third such session, the itching, sweating, mental disturbances, and complex nocturnal behavior improved and these symptoms completely disappeared after the sixth session, with improvement in insomnia and reduced muscle twitching. However, one month after the sixth PE session, there was a progressive worsening of insomnia and diurnal drowsiness, which promptly disappeared after another two PE sessions.
In one case there high dose steroid treatment resulted in a transient improvement, but aggressive immuno-suppressive therapy with cyclophosphamide was necessary to control the disease and result in a dramatic clinical improvement.
In another case, the subject was treated with prednisolone (1 mg/kg body weight) with carbamazepine, propanolol, and amitriptyline. After two weeks, improvement with decreased stiffness and spontaneous muscle activity and improved sleep was observed. After another 7–10 days, the abnormal sleep behavior disappeared completely.
In another case, symptomatic improvement with plasmapheresis, thymectomy, and chronic immunosuppression provide further support for an autoimmune or paraneoplastic basis.
Although thymectomy is believed to be a key element in the proposed treatment, there is a reported case of Morvan’s Syndrome presenting itself post-thymectomy.
Idiopathic craniofacial erythema is a medical condition characterised by severe, uncontrollable, and frequently unprovoked, facial blushing.
Blushing can occur at any time and is frequently triggered by even mundane events, such as, talking to friends, paying for goods in a shop, asking for directions or even simply making eye contact with another person.
For many years, the cause of the condition was thought to be an anxiety problem, caused by a mental health disorder. However, in recent years experts in the field of the disorder believe it to be caused by an overactive sympathetic nervous system, an automatic response which sufferers have no mental control over. It is related to focal hyperhidrosis, more commonly known as excessive sweating, as it is caused by the same overactive nerves which cause excessive sweating. Sufferers of severe facial blushing commonly experience focal hyperhidrosis. Studies have also shown that patients with severe facial blushing or focal hyperhidrosis commonly have family members with one or both of the related disorders.
Botulinum toxin is highly effective in the treatment of hemifacial spasm. It has a success rate equal to that of surgery, but repeated injections may be required every 3 to 6 months. The injections are administered as an outpatient or office procedure. Whilst side effects occur, these are never permanent. Repeated injections over the years remain highly effective. Whilst the toxin is expensive, the cost of even prolonged courses of injections compares favourably with the cost of surgery. Patients with HFS should be offered a number of treatment options. Very mild cases or those who are reluctant to have surgery or Botulinum toxin injections can be offered medical treatment, sometimes as a temporary measure. In young and fit patients microsurgical decompression and Botulinum injections should be discussed as alternative procedures. In the majority of cases, and especially in the elderly and the unfit, Botulinum toxin injection is the treatment of first choice. Imaging procedures should be done in all unusual cases of hemifacial spasm and when surgery is contemplated. Patients with hemifacial spasm were shown to have decreased sweating after botulinum toxin injections. This was first observed in 1993 by Khalaf Bushara and David Park. This was the first demonstration of nonmuscular use of BTX-A. Bushara further showed the efficacy of botulinum toxin in treating hyperhidrosis (excessive sweating). BTX-A was later approved for the treatment of excessive underarm sweating. This is technically known as severe primary axillary hyperhidrosis – excessive underarm sweating with an unknown cause which cannot be managed by topical agents (see focal hyperhidrosis).
Microvascular decompression appears to be the most popular surgical treatment at present. Microvascular decompression relieves pressure on the facial nerve, which is the cause of most hemifacial spasm cases. Excellent to good results are reported in 80% or more cases with a 10% recurrence rate. In the present series approximately 10% had previously failed surgery. Serious complications can follow microsurgical decompressive operations, even when performed by experienced surgeons. These include cerebellar haematoma or swelling, brain stem infarction (blood vessel of the brain stem blocked), cerebral infarction (ischemic stroke resulting from a disturbance in the blood vessels supplying blood to the brain), subdural haematoma and intracerebral infarction (blockage of blood flow to the brain). Death or permanent disability (hearing loss) can occur in 2% of patients of hemifacial spasm.
There is no known cure for neuromyotonia, but the condition is treatable. Anticonvulsants, including phenytoin and carbamazepine, usually provide significant relief from the stiffness, muscle spasms, and pain associated with neuromyotonia. Plasma exchange and IVIg treatment may provide short-term relief for patients with some forms of the acquired disorder. It is speculated that the plasma exchange causes an interference with the function of the voltage-dependent potassium channels, one of the underlying issues of hyper-excitability in autoimmune neuromyotonia. Botox injections also provide short-term relief. Immunosuppressants such as Prednisone may provide long term relief for patients with some forms of the acquired disorder.
The long-term prognosis is uncertain, and has mostly to do with the underlying cause; i.e. autoimmune, paraneoplastic, etc. However, in recent years increased understanding of the basic mechanisms of NMT and autoimmunity has led to the development of novel treatment strategies. NMT disorders are now amenable to treatment and their prognoses are good. Many patients respond well to treatment, which usually provide significant relief of symptoms. Some cases of spontaneous remission have been noted, including Isaac's original two patients when followed up 14 years later.
While NMT symptoms may fluctuate, they generally don't deteriorate into anything more serious, and with the correct treatment the symptoms are manageable.
A very small proportion of cases with NMT may develop central nervous system findings in their clinical course, causing a disorder called Morvan's syndrome, and they may also have antibodies against potassium channels in their serum samples. Sleep disorder is only one of a variety of clinical conditions observed in Morvan's syndrome cases ranging from confusion and memory loss to hallucinations and delusions. However, this is a separate disorder.
Some studies have linked NMT with certain types of cancers, mostly lung and thymus, suggesting that NMT may be paraneoplastic in some cases. In these cases, the underlying cancer will determine prognosis. However, most examples of NMT are autoimmune and not associated with cancer.
The treatment of dysautonomia can be difficult; since it is made up of many different symptoms, a combination of drug therapies is often required to manage individual symptomatic complaints. Therefore, if an autoimmune neuropathy is the case, then treatment with immunomodulatory therapies is done, or if diabetes mellitus is the cause, control of blood glucose is important. Treatment can include proton-pump inhibitors and H2 receptor antagonists used for digestive symptoms such as acid reflux.
For the treatment of genitourinary autonomic neuropathy medications may include sildenafil (a guanine monophosphate type-5 phosphodiesterase inhibitor). For the treatment of hyperhidrosis, anticholinergic agents such as trihexyphenidyl or scopolamine can be used, also intracutaneous injection of botulinum toxin type A can be used for management in some cases.
Balloon angioplasty, a procedure referred to as transvascular autonomic modulation, is specifically not approved for the treatment of autonomic dysfunction.
Galvanic urticaria has been described after exposure to a galvanic (electrical) device used to treat hyperhidrosis.
The prognosis of dysautonomia depends on several factors; individuals with chronic, progressive, generalized dysautonomia in the setting of central nervous system degeneration such as Parkinson's disease or multiple system atrophy have a generally poorer long-term prognosis. Consequently, dysautonomia could be fatal due to pneumonia, acute respiratory failure, or sudden cardiopulmonary arrest.
Autonomic dysfunction symptoms such as orthostatic hypotension, gastroparesis, and gustatory sweating are more frequently identified in mortalities.
There are only about 14 reported cases of Morvan's syndrome in the English Literature. With only a limited number of reported cases, the complete spectrum of the Central Nervous System (CNS) symptomatology has not been well established. The natural history of Morvan’s is highly variable. Two cases have been reported to remit spontaneously. Others have required a combination of plasmapheresis and long term immunosuppression, although in one of these cases the patient died shortly after receiving plasma exchange (PE). Other fatalities without remission have been described by, amongst others, Morvan himself.
The exact incidence of Frey syndrome is unknown. The disorder most often occurs as a complication of the surgical removal of a parotid gland (parotidectomy). The percentage of individuals who develop Frey syndrome after a parotidectomy is controversial and reported estimates range from 30-50 percent. In follow-up examinations, approximately 15 percent of affected individuals rated their symptoms as severe. Frey syndrome affects males and females in equal numbers.
Acrocyanosis is common initially after delivery in the preterm and full term newborn Intervention normally is not required, although hospitals opt to provide supplemental oxygen for precautionary measures.
There is no standard medical or surgical treatment for acrocyanosis, and treatment, other than reassurance and avoidance of cold, is usually unnecessary. The patient is reassured that no serious illness is present. A sympathectomy would alleviate the cyanosis by disrupting the fibers of the sympathetic nervous system to the area. However, such an extreme procedure would rarely be appropriate. Treatment with vasoactive drugs is not recommended but traditionally is mentioned as optional. However, there is little, if any, empirical evidence that vasoactive drugs (α-adrenergic blocking agents or calcium channel blockers) are effective.
Night sweats, also known as nocturnal hyperhidrosis, is the occurrence of excessive sweating during sleep. The person may or may not also suffer from excessive perspiration while awake.
One of the most common causes of night sweats in women over 40 is the hormonal changes related to menopause and perimenopause. This is a very common occurrence during the menopausal transition years.
While night sweats might be relatively harmless, it can also be a sign of a serious underlying disease. It is important to distinguish night sweats due to medical causes from those that occur simply because the sleep environment is too warm, either because the bedroom is unusually hot or because there are too many covers on the bed. Night sweats caused by a medical condition or infection can be described as "severe hot flashes occurring at night that can drench sleepwear and sheets, which are not related to the environment". Some of the underlying medical conditions and infections that cause these severe night sweats can be life-threatening and should promptly be investigated by a medical practitioner.
Frey's syndrome often results as a side effect of surgeries of or near the parotid gland or due to injury to the auriculotemporal nerve, which passes through the parotid gland in the early part of its course. The Auriculotemporal branch of the Trigeminal nerve carries parasympathetic fibers to the sweat glands of the scalp and the parotid salivary gland. As a result of severance and inappropriate regeneration, the parasympathetic nerve fibers may switch course, resulting in "gustatory Sweating" or sweating in the anticipation of eating, instead of the normal salivatory response.
It is often seen with patients who have undergone endoscopic thoracic sympathectomy, a surgical procedure wherein part of the sympathetic trunk is cut or clamped to treat sweating of the hands or blushing. The subsequent regeneration or nerve sprouting leads to abnormal sweating and salivating. It can also include discharge from the nose when smelling certain food.
Rarely, Frey's syndrome can result from causes other than surgery, including accidental trauma, local infections, sympathetic dysfunction and pathologic lesions within the parotid gland.
An example of such, rare trauma or localized infection; can be seen in situations where a hair follicle has become ingrown and is causing trauma or localized infection near or over one of the branches of the auriculotemporal nerve.
Pitted keratolysis can be reduced and eventually stopped by regularly applying a liberal amount of antiperspirant body powder to the inside of the shoes and socks of the sufferer. Regular powder application will greatly reduce foot perspiration and keep the plantar surface of the foot dry therefore creating an environment hostile to the Corynebacterium.
Ross' syndrome consists of Adie's syndrome (myotonic pupils and absent deep tendon reflexes) plus segmental anhidrosis (typically associated with compensatory hyperhidrosis).
It was characterized in 1958 by A.T. Ross.
By 1992, eighteen cases had been documented.
The condition may be a sign of various disease states, including but not exclusive to the following:
- Cancers
- Lymphoma
- Leukemia
- Infections
- HIV/AIDS
- Tuberculosis
- Mycobacterium avium-intracellulare infection
- Infectious mononucleosis
- Fungal infections (histoplasmosis, coccidioidomycosis)
- Lung abscess
- Infective endocarditis
- Brucellosis
- Pneumocystis pneumonia (most often - in immunocompromised individuals)
- Endocrine disorders
- Menopause
- Premature ovarian failure
- Hyperthyroidism
- Diabetes mellitus (nocturnal hypoglycemia)
- Endocrine tumors (pheochromocytoma, carcinoid)
- Orchiectomy
- Rheumatic disorders
- Takayasu's arteritis
- Temporal arteritis
- Other
- Obstructive sleep apnea
- Gastroesophageal reflux disease
- Chronic fatigue syndrome
- Fibromyalgia
- Granulomatous disease
- Chronic eosinophilic pneumonia
- Lymphoid hyperplasia
- Diabetes insipidus
- Prinzmetal's angina
- Anxiety
- Pregnancy
- Drugs
- Antipyretics (salicylates, acetaminophen)
- Antihypertensives
- Dinitrophenol - a common side effect
- Phenothiazines
- Drug withdrawal: ethanol, benzodiazepines, heroin (and other opiates),
- Over-bundling
- Autonomic over-activity
- IBD (inflammatory bowel disease) - Crohn's disease/ulcerative colitis