An interventional radiology solution of ethanol sympatholysis might help treat more than just primary hyperhidrosis—it could stop associated arrhythmias, but these are very early data and much more research is needed to answer the big questions, writes Christos Georgiades.
Primary hyperhidrosis, excessive sweating, is a manifestation of a pathologically hyper-active sympathetic system. Conservative estimates place its prevalence at three million Americans, whose lives are severely affected by it.
It commonly presents in the second decade of life, a factor that magnifies its social impact. Primary hyperhidrosis can lead to isolation, bullying and even suicide attempts in early life, while later, it can cause difficulties in initiating and maintaining relationships, lead to employment loss and even psychiatric illness. Beyond the sociopsychiatric issues, patients may suffer from recurrent or chronic bacterial or fungal cellulitis. The number of treatment choices rather reflects their ineffectiveness, and they include antidepressants, behavioural modification, antiperspirants, oral anticholinergics, Iontophoresis, topical laser treatment or botox injections. Predictably, most patients exhaust most if not all options, and suffer through their very common side effects. To make matters worse, none of these treatments is very effective or permanent. Surgical sympathectomy, ligation of the para-vertebral sympathetic chain (usually at T2, 3 and/or 4) offers the best chance for a permanent cure, however it comes with a 60–70% risk of compensatory hyperhidrosis, the reactive development of hyperhidrosis in previously non-affected areas.
So where does interventional radiology fit into this? Well, it is the old cocktail that keeps us thriving as a specialty: recognising a void, exploiting an opportunity, image-guidance expertise, mixing it with a bit of creativity and yes, luck. The tools? A needle and a few cubic centimetre of alcohol.
The results of our pilot study—an admittedly small group of eight very desperate patients—claim a 75% primary and a 94% secondary efficacy, two years on and counting.An outcome much better than any of the non-surgical options and on-par with the surgical treatment, without the risk of compensatory hyperhidrosis. The procedure is performed on an outpatient basis, the effect is immediate, comes with minimal/manageable risks (pneumothorax 12%, temporary Horner’s syndrome reported at 10%, but we saw none in our series).
The best part of all, is the effect this procedure has on patients’ lives. They can now drive without fearing their wet hands will cause them to lose control; can shake hands and keep them out of their pockets; go out to dinner. They do not have to carry five changes of clothes everywhere they go, or avoid writing for fear of wetting the paper, or lose their job, or isolate themselves. To be sure, the sentiment in this last paragraph is premature considering the small number of patients in our study, but sometimes one knows something will work before one can prove it.
We recognised a void, exploited an opportunity, had the technical expertise and mixed in a bit of creativity. So, why, luck? We knew the anatomy, we knew the pathophysiology, we had the tools. Then, one of our patients with head/facial primary hyperhidrosis had another (possibly related) diagnosis: postural tachycardia syndrome (PoTS). She had multiple daily attacks of symptomatic tachycardia occasionally complicated by syncopal episodes and was unresponsive to treatment. She was treated with our standard protocol for this kind of primary hyperhidrosis: Bilateral, CT-guided, ethanol ablation of T2 sympathetic ganglia. Her excessive sweating resolved immediately after treatment…and so did her arrhythmia.
What lies ahead? Well next, comes the hard work. Can this simple procedure be an effective treatment for certain types of arrhythmias? If yes, which ones? What is the anatomic and functional relationship between the sympathetic system and the heart muscle and/or the pacemaker cells?
Can hypertension be mediated this way? These are all questions that only properly designed studies can address.
Nevertheless, these are exciting prospects, possibly opening up a new area of intervention for interventional radiology. Onwards.
Christos Georgiades is an associate professor of Radiology and Surgery and director, Interventional Oncology and vice-chair, Department of Radiology, Johns Hopkins University, Baltimore, USA. He has reported no disclosures relevant to this article.
