Hyperhidrosis is a condition of excessive sweating in the hands (palmar hyperhidrosis), armpits (axillary hyperhidrosis) or feet (plantar hyperhidrosis). This sweating is independent of exercise or heat. It is a benign condition but can have a serious impact on a patient’s quality of life. It occurs in up to 3% of the population. The exact cause of hyperhidrosis is unknown but there may be a genetic component with some families having many members with this condition. It is known that sweating is controlled by the sympathetic nervous system. This set of nerves helps regulate our body temperature by controlling the sweat glands. These nerves are not under a patient’s voluntary control. Hyperhidrosis is an inappropriate control of these glands that leads to excessive sweating.
Generalized hyperhidrosis: Affects large areas of the body with excessive sweating, typically in adults whose sweating occurs during both waking and sleeping hours.
Localized hyperhidrosis: These individuals have excessive sweating that occurs in specific parts of the body that markedly impacts their quality of life and self-image.
Palmar: This sweating occurs in the palms of the hands. It can occur spontaneously but can be worsened by stress, anxiety or exercise. The hands become soaking wet which makes it difficult to grasp objects, drive or shake hands. The hands are typically clammy and cool. Over time, patients avoid hand-shaking and become extremely anxious about social environments.
Axillary and Plantar: Patients with axillary (armpit) hyperhidrosis sweat profusely from their underarms causing them to soak their clothes shortly after they dress. This serves as a social embarrassment. Many patients resort to wearing baggy shirts and sweatshirts and change their clothes multiple times a day. Plantar hyperhidrosis is the excessive sweating of the soles of the feet leading to soaked socks and significant foot odor.
Antiperspirants: Antiperspirants and topical drying agents are the first line treatment for hyperhidrosis. These are available over the counter or as a prescription (typically aluminum chloride) from your primary care physician or a dermatologist. Other treatment options include iontophoresis. This consists of a daily home treatment of electrical stimulation to the affected area with a portable device.
Botulinum toxin (Botox): Botox treatment involves injecting small doses of the toxin in and around the sweat glands to decrease sweat production. It remains effective for up to 6 months. Repeated injections are required to maintain the effect.
Surgery is an option to treat severe hyperhidrosis in patients who have failed topical therapies. The surgical treatment involves dividing the sympathetic chain which is the nerve that conducts the abnormal stimulation to the sweat glands. The sympathetic chain runs vertically along the ribs and is located about an inch away from the bony spine and is easily identified by the surgeon. Sympathectomy is the operative division of that nerve. The sympathetic chain is typically cut and divided or, in addition, a short portion of the chain is removed.
Surgery for hyperhidrosis is routinely performed by minimally invasive techniques. ETS – endoscopic thoracic sympathectomy (also known as thoracoscopic sympathectomy or sympathicotomy) is the most frequently used method. The operation is performed using a tiny telescope (5 mm) and two small access incisions of approximately the same size. A video-telescope is passed into the chest cavity through one of these incisions. This allows visualization of the sympathetic chain. Through the other incision, instruments are placed to allow the surgeon to divide the chain at the specific level according to the patient’s symptoms. The operation is performed on both sides of the patient. The operation takes approximately one hour to perform and most patients are discharged home the day of surgery. Patients can return to work almost immediately.
The most common side-effect of hyperhidrosis surgery is compensatory sweating. Compensatory sweating is the report of increased sweating after surgery in an area that was not originally the source of a patient’s complaint. The back, buttocks and thighs are areas most prone to compensatory sweating. While many patients experience some degree of compensatory sweating, it is typically mild and the vast majority of patients are extremely satisfied with the results of their surgery and report improved quality of life. It is very rare for compensatory sweating to be so severe that the symptoms are worse than prior to surgery.