Hyperhidrosis, Mycosis Fungoides & Unknown Rashes
What is hyperhidrosis? Hyperhidrosis is a fancy word for excess sweating. It often occurs in the armpits but also may happen on the palms and soles. Rarely, people have excess sweating over all of their body.
What are the symptoms of hyperhidrosis? Symptoms include dripping wet hands, such that paper gets wet when writing, or wet armpits requiring a change of shirt during they day, perhaps sweating through a second layer of clothing. Socks may get particularly damp, even without strenuous physical activity. Sweating may be triggered by nervousness but sometimes occurs at no particular time.
How is hyperhidrosis diagnosed? Generally, the diagnosis is made by patient self-report and is somewhat subjective. However, anything more than a moist handshake while someone is at rest in a temperate room constitutes hyperhidrosis.
What are the treatment options for hyperhidrosis? Aluminum chloride 20% gel applied once to twice daily is a first-line regimen. Aluminum chloride 30% in ethanol applied at night is another option. Another effective option is Botox (onabotulinumtoxinA) or Dysport (abobotulinumtoxinA) injected every 3-6 months in the affected areas. There is a laser, MiraDry, that allows for permanent destruction of axillary sweat glands. It is not indicated for palms and soles. Finally, surgically cutting of sympathetic nerve chains that innervate the palms or axillae is an extreme solution.
What is mycosis fungoides? Mycosis fungoides is another name for cutaneous T-cell lymphoma. It is a type of skin cancer caused by uncontrolled division of cancerous T-cells, a type of immune system cell. It occurs as a flat rashed, a raised rash, tumors of the skin, or as red skin all over (when this happens, it is called Sezary syndrome). When someone has swollen lymph nodes, blood involvement, or internal organ involvement, the disease has a poorer prognosis. When it is flat and involves just the skin, the disease is often easily treatable.
What are the symptoms of mycosis fungoides? Most commonly, people merely have the rash without symptoms. Sometimes, the rash can be extremely itchy. If they are red all over, patients may experience chills. If the lymphoma involves internal organs, people may feel tired or experience weight loss, night sweats, or fevers.
How is mycosis fungoides diagnosed? Diagnosis is made by skin biopsy. Often, the biopsy comes back as eczema or as something nonspecific. It may take multiple biopsies to make the diagnosis. Sometimes, the disease must progress to its full form in order for the diagnosis to be made definitively by biopsy. Lymph node biopsy is another means of assisting diagnosis, as is PET CT scan.
What are the treatment options for mycosis fungoides? Treatment options for mycosis fungoides are growing as scientific understanding of the immune system and cancer evolves. First line therapy for stage I disease (when it is flat) includes phototherapy, topical bexarotene, topical nitrogen mustard, and photodynamic therapy. When disease is more advanced, oral and injectable options, including bexarotene, methotrexate, interferon, extracorporeal photopheresis, and histone deacetylase (HDAC) inhibitors such as vorinistat can help. For advanced disease, conventional chemotherapy, radiation therapy, and bone marrow or cord blood transplantation can be employed.
Frequently, a patient may come to the office with a rash whose diagnosis is not readily obvious. A dermatologist's approach attempts to be systematic in finding a correct diagnosis. We start by taking a careful history, outlining symptoms that might fit with one rash or another. Identifying when the rash occurred, in what context (i.e., after a trip or some exposure), alleviating factors, and whether or not it itches give us clues. If we cannot match your rash with something that we recognize readily, we often will take a skin biopsy. Other times, we may broadly classify the rash as either infectious (like a fungus or bacteria) or inflammatory (meaning due to an overactive immune system reaction in the skin). As such, we can treat the rash empirically without knowing what it is, according to our best guess about the nature of the rash. If the rash gets better with our chosen therapy, then the treatment helps us to diagnose the rash.