I . Introduction
Hyperhidrosis is a clinical disorder characterized by excessive sweating. Depending on the cause of the condition, hyperhidrosis is classified as either primary hyperhidrosis or secondary hyperhidrosis, also it can affect the entire body or certain parts of the body. Primary hyperhidrosis is generally regarded as the localized hyperhidrosis that affects only certain parts of the body and is caused by the imbalance of sympathetic and parasympathetic nerves in the autonomic nervous system1.
According to a Japanese epidemiological study of primary hyperhidrosis, 5.33% of excessive sweating occurs on the palm, 2.79% in the armpits while 4.7% affects the head area2. According to a university hospital in South Korea, 34.1% of patients with the condition had a known family history, the condition becomes apparent during the teenage years3.
According to the statistics from the Health Insurance Review & Assessment Service of Korea, more than 7000 people received hospital treatments for primary hyperhidrosis (R610) between 2016 and 2019, and 70% of patients aged between 10 and 30. Primary hyperhidrosis has an onset during the teenage years when older adults are rarely affected by the condition4.
In modern medicine, hyperhidrosis is often managed with non-invasive techniques, involving anticholinergic drugs or topical applications of aluminium chloride solutions on the affected areas. This has a relatively good effect in reliving the symptoms. However, the result is often temporary. Some invasive treatments - used in modern medicines - include the botulinum toxin (Botox) injections, eccrine gland disruption using laser or ultrasound and endoscopic thoracic sympathectomy (ETS) a surgery in which involves destroying a portion of the sympathetic nerve trunk in the thoracic region5,6. ETS has been considered an effective treatment the hyperhidrosis. However, despite its well-established success rate, ETS can also cause some fatal complications such as surgical infections while removing the sweat glands and some compensatory sweating7.
Due to the limitations and the risk of adverse effects associated with modern medical treatments, the number of patients with hyperhidrosis who become interested in trying Korean medicine treatments is steadily growing8. Furthermore, medical studies evidencing the efficacy of Korean medicine to treat hyperhidrosis are published continuously. In Korean medicine, hyperhidrosis is regarded as a fever in gastric organs, cardiomyopathy and weakened qi. Basic herbal medicine prescribed to treat hyperhidrosis include: Jinaetang, Daeshihotang, Gamipalmultang, Bohyolansintang, Bojungikgitang, Danguiyukhwangtang9,10.
Iris diagnosis is a registered diagnostic method used in Korean medicine practice. The iris is a cranial nerve tissue made from the ectoderm of the brain that begins to form from the 4th week of embryonic development11. As an organ, the iris controls the amount of light pass through the back of the eyes. It is widely studied that the iris represents major parts of the organs and that several genetic conditions can be detected by looking at the iris12. The Korean iris diagnosis is based on the analysis of the genetic markers that include colours, structures, pigments, decolourization, nerve ring, etc. These elements play an important role in understanding Han-Yeol-Jo-Seup(cold-heat -dry-wet) types in Sasang constitutions and also evaluating the performance of the five major organs13.
In this case study, the patient with hyperhidrosis was first diagnosed her Sasang constitution, using the Korean medicine diagnostic method and further examined with iridology. The results indicated that her sympathetic nervous system was hyperactive. Consequently, a Korean herbal medicine was prescribed to the patient to improve her condition. Even though her conditions weren’t relieved with several medical treatments she tried in the past, the result of this trial was highly positive.
II. Case
A. IRB Review
This case study investigates a 37-year-old female patient with hand and foot hyperhidrosis, visiting the hospital from June 15 2021 to July 17 2021. The study follows the Case Report Guidelines (CARE guidelines) also it has been reviewed by the IRB 1040647-202108-HR-004-01.
B. History
On the 14th of June, the patient made her first hospital visit due to hand and foot hyperhidrosis. The condition became apparent at the age of 7 and gradually worsened. In her adolescent years, she had to take 3 to 4 handkerchieves to wipe her hands at exams. She was suggested to consider surgery by a Western medicine hospital. However, the patient objected to the surgery due to the potential adverse effects. At the age of 37, working as a psychologist, her excessive sweating on her hands and feet disrupted her daily routines and caused social withdrawal. When suggested a Korean medicine treatment for hyperhidrosis, the patient was hesitant at first, as all her previous medical attempts made weren’t satisfactory. However, she agreed to try the Korean herbal medicines after a couple of days of consideration.
C. Examination findings
At the first consultation, the patient’s palms were drenched in sweat, and the consulting form she was holding were wet. She is 161 cm in height, 68 kg, BMI 26.23, slightly yellow-toned skin and overweight. Her tongue was coated with yellow and white fur while her pulses were floating and tight. Other areas such as her appetite, digestion, urine, sleep, menstrual patterns were within a normal range. The abdomen examination indicated that she was Taeeum constitution also she had a low level of abdomen discomfort. She was easy to flush and tensed when stressed.
Dr Camscope Pro LED (Sometech, Seoul, Korea, Fig. 1) was used for iris photographing device. The installed LED lamp has a colour temperature of 6500 K, close to the natural light. The photographing procedures were as follow: The patient is seated in a chair, rested for a while. The patient places her eye in close contact with the device to prevent any ambient light interferences. Allowed a couple of seconds to adapt the LED light coming from the device. Repeated the same procedures for the other eye. The photography resolution was set to 1280×960 pixels, and the 75 mm long eyepiece magnified the view by 25 times.
According to the iris image(Fig. 2) taken for diagnosis, the diagnostic markers, such as Lacuna, Crypts had neither defects nor weakened tissues. However, the Collarette and Nerve rings were notably defined and thick, which indicated that her sympathetic nerve glands were overly active14.
Fig. 2
The numbered lines point toward pathophysiological markers of the patient’s iris.
(1) wet type, (2) collarette, (3) nerve ring
D. Therapeutic Intervention
According to the examination findings, herbal medicines were formulated following the recipes of Taeeumjowi-tang and Banhabaekchulcheonma-tang which was aimed at relieving excessive fluid retention and reducing hyperactivity in the sympathtic nervous systems in the brain were used with additional use of Bupleuri Radix, Coptidis Rhizoma, Scutellariae Radix15 to help suppress hyperactive sympathetic nerve systems and Artemisiae Capillaris Herba, Cocicis Semen, Alimatis Rhizoma, Polyporus to relieve water retention and heat.
One dosage contains a 100 cc herbal drink, directed to take twice a day for 30 days. The ingredients and usage per dose are as follows (Table 1):
Table 1
Composition of Taeeumjowi-tang and Banhabaekchulcheonma-tang Gagambang
E. Assessment Methods
The Hyperhidrosis Disease Severity Scale (HDSS) formulate by the Canadian Hyperhidrosis Advisory Committee was used to assess the severity of the condition. HDSS is the most widely used measurement of treatment efficacy in clinical studies. A 1-point improvement in HDSS score has been associated with a 50% reduction in sweat production and a 2-point improvement with an 80% reduction. It is one simple question with four answers designed to provides a qualitative measure of the severity of the patient’s condition based on how it affects daily activities16 (Table 2).
Table 2
The Hyperhidrosis Disease Severity Scale
Table 3
Treatment Course
F. Treatment course
The patient had an HDSS score of 4 at the initial hospital visit made on June 14, 2021. On June 18, 3 days into her treatment showed no sign of improvement. Due to the patient moving homes, she came back to the hospital on 11 July. She explained her symptoms began to improve from day 4, and sweating still affects her daily activities but the amount had reduced by 50%. Her HDSS score at this time was 3. On her following visit on July 17, she stopped taking the medicine due to stomach discomforts by 10 days, her HDSS score stayed at 3. On her final visit, 28 July, she explained that her sweating seldom affected her daily activities, with an HDSS score of 2.
III. Conclusion and Consideration
For the last 30 years, the patient has experienced physical and emotional discomforts due to excessive sweating on her hands and feet. Through iridology, we diagnosed her conditions, recognised the causes and prescribed a herbal medicine formulated based on Banhabaekchulcheonma-tang, Taeeumjowi-tang Gamibang to relieve excessive fluid retention with additional herbs such as Gastrodiae Rhizoma, Polygalae Radix, Bupleuri Radix, Lonicerae Flos to reduce hyperactivity in the sympathetic nervous systems in the brain. It showed that the patient’s stress-induced sweating had decreased in frequency and severity during the 6 weeks of our treatment course. Consequently, a significant result was obtained illustrating that sweating in the hands and feet was reduced by more than 80% compared to before taking the herbal medicine treatment.
In modern medicine, anticholinergic drugs are used on the affected areas to block the tubes leading from sweat glands to the skin surface. Anticholinergic drugs are used once a day on an affected area for up to 4 weeks. About 60% to 70% of patients describe that sweating reduced by 50%17. In this case study, the patient was given a 5-week course of herbal medicine. On competition of the course, it was demonstrated that sweating was significantly reduced by 70% in which could be regarded as a more effective treatment for hyperhidrosis in comparison to the modern treatments involving anticholinergic drugs.
These are the type of Byeonjeung(pattern differentiation) used in treating hyperhidrosis using Korean medicines: Jangbu-Byeonjeung, Sasang Constitution Byeonjeung, Yukgyeong-Byeonjeung, Gihyeol-Byeonjeung. For treating Jangbu-Byeonjeung, following Byeonjeung were used: Biwiseupdam, Biwigiheo, Wiyeol, Simbiyangheo, Simbyeongjeung, Gandamseubyeolhaju and Sineumheo. For Sasang Constitution Byeonjeung, Hyunggyeongnyeoljeung, Sinyeoldutongmangeumjeung were used for Soyangin while Wiwanhanjeung was used for Taeeumin, Ulgwangjeung, Taeeumbyeong-Gworeumjeung and Mangyangjeung for Soeumin. There were cases of Yukgyeong-Byeonjeung being diagnosed as Taeyangbyeong-Geolhyungjeung and Gwoleumbyeong. Qihyeol-Byeonjeung was categorized either Qiheo and Qichehyeoleo8.
In this case study. the diagnosis of the hyperactive sympathetic nervous system was made based on the diameter and thickness of collarette and nerve rings in the iris. In Fig. 1, the collarette in (2) is appearing thicker than average which indicates that the sympathetic nervous system is overly active18. Divided by collarette, Iris sphincter and iridodilator contract and relax sympathetic and parasympathetic nerves19. Yung-Hui Li defines 5 constitutions by the shapes of collarette. When collarette is positioned lesser than 1/3 diameter of iris the constitution is defined as Fire20. In this case study, the patient’s collarette was shorter than 1/3 diameter of the iris, categorized as ‘Fire.’. In Korean medicine ‘Fire’ represents fever therefore diagnosing heat in sympathetic nervous systems in this case study21. The nerve ring is the bright-line appearing outer side of the ciliary body. This is a physiological and pathological marker that can detect abnormal stimulation of the sympathetic nervous system. It is related to the thickness and density of the iris and is determined by the hypoplasia or density of some or all of the five cell membranes in the iris. Larsson conducted a study investigating a correlation between personality traits and iris22. His finding suggests the nerve rings were associated with neurotic behaviours such as impulsiveness. It suggests that people with a higher number of nerve rings had lower ability to control desires and impulses. In particular, the patterns of the Pax-6 gene in the iris and brain also differences in iris tissues and brain structures influence a person’s personality. The sympathetic nervous system is shown in the iris and the Pax-6 gene expression in the brain, the nervous tension glands in the iris show differences in the tissues of the iris and differences in brain structure23. The nerve ring in the iris was an important marker for examining sympathetic nervous systems in the brain, especially, the Pax-6 genes also the differences in iris tissues and brain structures. Based on his findings, we could argue that the nerve rings in the iris could be seen as an important diagnostic marker for hyperactivity in the sympathetic nervous systems.
In this case study, we used iridology to diagnose hyperactivity in sympathetic nervous systems and prescribed Korean herbal medicine to treat a patient with chronic hyperhidrosis which persisted over 30 years. With our course of treatment the patient’s symptoms were significantly reduced by 80%. However, it is just one case study with limitations. We believe that further diagnostic examinations, reviewing the changes in central nervous systems more objectively, using autonomic nerve testing (heart rate variability, HRV) would be much needed in the future.
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