Effectiveness of microwave treatment for hyperhidrosis and osmidrosis after curettage failure

Dear Editor, Sweat-related body malodour manifests in essentially all individuals at some point during life, usually related to hyperhidrosis (excessive sweating). The degree of malodour considered “pathological” and sufficient for a diagnosis of bromhidrosis or osmihidrosis (sweat with a very strong odor) is not established so the disease is generally diagnosed when noticeable body odor has a negative effect on either individual's self-view, social interactions, or quality of life. Current estimations point to a prevalence of hyperhidrosis at 4.8%, which represents approximately 15.3 million people in the United States, and the prevalence of osmidrosis is unkown. Selection of the appropriate approach to treatment implies consideration of the anatomical location, disease severity, patient's expectations, preferences and safety concerns. The major therapeutic options for axillary bromhidrosis include antiperspirants, botulinum toxin, microwave thermolysis, anticholinergic drugs, and surgery (Table 1). Microwave energy device can cause irreversible thermolysis of the eccrine and apocrine sweat glands and relieve hyperhidrosis and osmidrosis in the axilla. Its commercialization was supported by a randomized trial in 2012. The underlying mechanism is selective heating of water rich structures as is the eccrine glands with heating up to cell death resulting in gland elimination. A 28-year-old healthy man presented to our clinic with the complaint of hyperhidrosis and bromhidrosis since adolescence. This negatively affected his social interaction and quality of life. He had tried several over-the counter antiperspirants and several cycles of iontophoresis with partial improvement but not enough to his expectations. He was not under any medication and opposed treating his condition with drugs. Finally, 20 months before the present consultation, the patient underwent surgical curettage under general anesthesia. Postoperatory edema, bruising, and pain persisted for months. After an initial improvement, the patient continued with hyperhidrosis and osmihidrosis that started 3 months after surgery, with a Hyperhidrosis Disease Severity Scale (HDSS) of 4 at the moment of the consultation. Examination and blood tests were performed to rule out hyperthyroidism, tuberculosis, and malignancy. On examination the patient presented scarring on both axillae (Figure 1). It was indicated to treat the area with microwavebased therapy MiraDry system (Miramar Labs, Sunnyvale, CA) after explaining the potential interference of scarring with this therapy. The procedure was applied under tumescent anesthesia to both axillary regions, with a 180 × 60 mm template adjusted to the patient size. Minor starch-iodine test was performed to locate the sweating areas. During the first week, the patient developed subcutaneous nodules and edema that required a non-steroidal anti-inflammatory drug. Ten months after the procedure, HDSS was 1 and no sideeffects were present. Microwave-based therapy has shown to be effective in different reports (Table 2). Compared to surgery, continued hyperhidrosis after suction curettage may occur as a result of skipped areas, compensatory sweating, or reinnervation of remaining sweat glands. The skill of the surgeon performing the procedure may influence the failure rate and