Hyperhidrosis: Treatment Options and Surgical Insights

Some issues related to hyperhidrosis?

Hello, Doctor! I am someone who suffers from palmar hyperhidrosis.
I have come across some questions raised by others online that are very similar to my situation, but they remain unanswered.
I would like to know the answers to these questions as a basis for deciding whether to undergo surgery or what type of treatment to pursue.
I apologize for the length of this message, and I would greatly appreciate your insights! Thank you very much! Below are the main concerns and questions:
Hello, Doctor.
I am a male student who has been suffering from hyperhidrosis for over twenty years.
I have severe sweating in my hands and feet, which causes me significant distress.
It makes me hesitant to initiate friendships, and I try to avoid handshakes.
Whether I am using a computer, learning to drive, riding a motorcycle, or doing anything else, it is very troubling, and I feel helpless and unsure of what to do.
I often wonder why, despite advancements in medicine, there is no better treatment for palmar hyperhidrosis.
I long to be a normal person, but I feel trapped by this condition.
I have many questions, and that is why I am reaching out to you.
Here is a summary of the information I found online:
Non-surgical (Medical Treatments)
A.
Oral Medications: Anticholinergic medications provide only temporary relief and can cause systemic side effects such as dry mouth, making them rarely used.
B.
Aluminum Chloride Solution: This can inhibit sweating but must be applied daily and is only effective for mild symptoms, reducing sweating by about 30%.
C.
Iontophoresis: This treatment can provide effects lasting about one to two weeks.
D.
Botulinum Toxin: Method: The drug binds to the proteins at the sympathetic nerve endings and is injected locally into the skin or subcutaneously, blocking local sweat gland secretion.
Effectiveness: Can reduce sweating by 40-85%.
Advantages: Does not cause compensatory sweating.
Disadvantages: Requires repeated injections as effects last only three to twelve months, and it can be expensive.
Surgical (Surgical Treatments)
A.
Thoracoscopic Sympathectomy: Method: Removal of the second and third thoracic sympathetic ganglia on both sides.

1.
Advantages:
- Minimal damage
- Few complications
- Can be appropriately excised without increasing the risk of recurrence.
2.
Disadvantages:
- Compensatory sweating can occur in up to 90% of cases, with over one-third experiencing moderate to severe compensatory sweating, primarily affecting the body, back, buttocks, and thighs, but mostly within reasonable limits.
- The incidence of pneumothorax is 2.4%, mostly mild, and the incidence of hemothorax is about 1%.
Long-term recurrence rates are only 1-2%, with some individuals experiencing dryness in their hands during winter requiring hand cream, and a small percentage (less than 2%) may experience recurrence.
3.
Effectiveness: Success rates for facial and palmar sweating can reach nearly 100%.
Axillary sweating can be as high as 90%, and plantar sweating is 60-70%.
B.
Titanium Alloy Vascular Clips: If troublesome compensatory sweating occurs post-surgery, these clips can be removed (60-70% improvement), and they do not stimulate the heart or cause asymmetry in the eyes, with other aspects being similar to thoracoscopic sympathectomy.
Questions:
1.
I would like to ask about a statement made by Dr.
Chen Jianli on his website regarding hyperhidrosis: "Based on our years of experience treating axillary sweating, cutting the third and fourth thoracic sympathetic ganglia while preserving the second thoracic sympathetic ganglion can still cure palmar hyperhidrosis, but compensatory sweating is significantly reduced." I have seen many websites discussing the removal of the second thoracic sympathetic ganglion rather than the third or fourth.
Which approach is the most effective in minimizing compensatory sweating?

2.
If titanium alloy vascular clips have the benefits mentioned, why is the surgical approach for hyperhidrosis still primarily sympathetic ganglion resection rather than using titanium clips? This is something I do not understand.
3.
To what extent can botulinum toxin treat hyperhidrosis? Can it achieve a level comparable to that of a normal person, or does it only reduce sweating while still causing discomfort?
4.
If I am considering surgery, which option should I choose: botulinum toxin, titanium alloy clips, or thoracoscopic sympathectomy? Which would be more suitable? Also, could you recommend a physician for this?
5.
I often see many people suffering from compensatory sweating or recurrence on various websites and forums.
Why is it that the recurrence and severe compensatory sweating rates for thoracoscopic surgery are reported to be low, yet some individuals still suffer from these issues? My mother’s colleague had a daughter who underwent surgery but experienced recurrence and still has compensatory sweating, which makes me hesitant to proceed with surgery.
However, not undergoing treatment is also quite distressing, and I fear that the potential complications may be even greater.
Thank you very much for your assistance!

Eric, 20~29 year old female. Ask Date: 2004/11/25

Dr. Xiao Furen reply Neurosurgery

1.
The best results are typically achieved with T2 + T3, but compensatory sweating may be more severe.
Some say that performing only T2 or T3 + T4 may result in less compensatory sweating, although I have also seen cases where T3 + T4 was performed and there was still palmar sweating.

2.
After the removal of the metal clips, it is not guaranteed that one can return to the original state, and it must be paid out of pocket, which can be costly.

3.
Botulinum toxin is injected into the hands, usually performed by dermatologists or plastic surgeons, and I have limited personal experience with this.

4.
Since you have gathered so much information and are aware of both the pros and cons, the decision should ultimately be made by you.

5.
The incidence of compensatory sweating is not low, but the likelihood of it severely affecting daily life is relatively low.

Reply Date: 2004/11/25

More Info

Hyperhidrosis, or excessive sweating, can significantly impact an individual's quality of life, especially when it affects the hands and feet. Understanding the treatment options available, including both non-surgical and surgical interventions, is crucial for those suffering from this condition.

Non-Surgical Treatment Options
1. Oral Medications: Anticholinergic medications can be prescribed to reduce sweating. However, they may cause systemic side effects like dry mouth and blurred vision, which can limit their use.

2. Aluminum Chloride Solutions: These topical treatments can be effective for mild cases of hyperhidrosis. They work by blocking the sweat glands but require daily application and may only reduce sweating by about 30%.

3. Iontophoresis: This method involves using a device that passes a mild electrical current through water and into the skin's surface, which can temporarily block sweat glands. The effects typically last one to two weeks.

4. Botulinum Toxin Injections: Botox is a popular treatment for hyperhidrosis. It works by blocking the nerves that cause sweating. The effectiveness can range from 40% to 85%, but the treatment needs to be repeated every 3 to 12 months, and it can be costly.

Surgical Treatment Options
1. Endoscopic Thoracic Sympathectomy (ETS): This surgical procedure involves cutting or clamping the sympathetic nerves that control sweating. It has a high success rate for treating palmar (hand) and axillary (underarm) hyperhidrosis, but it can lead to compensatory sweating in other areas of the body, which can be distressing for some patients. The risk of complications, such as pneumothorax (collapsed lung), is relatively low, but it is still a consideration.

2. Titanium Clips: This newer technique involves placing clips on the sympathetic nerves instead of cutting them. If compensatory sweating occurs, the clips can be removed, potentially alleviating the issue. However, this method is not as widely adopted as ETS.

Addressing Your Questions
1. Effectiveness of Nerve Sectioning: The debate over which sympathetic ganglia to cut (second, third, or fourth thoracic) is ongoing. Some studies suggest that preserving certain ganglia can reduce compensatory sweating. However, the most effective approach may vary from patient to patient, and it is essential to consult with a surgeon experienced in these techniques.

2. Preference for ETS over Titanium Clips: The reason ETS is more commonly performed than the titanium clip method may be due to the established track record of ETS in providing immediate results for hyperhidrosis. The titanium clip method is still relatively new and may not have as much long-term data supporting its efficacy.

3. Effectiveness of Botox: While Botox can significantly reduce sweating, it may not completely eliminate it. Many patients report a substantial improvement, but some sweating may still occur, especially in stressful situations.

4. Choosing the Right Treatment: The choice between Botox, titanium clips, or ETS depends on the severity of your hyperhidrosis, your lifestyle, and your personal preferences. Consulting with a dermatologist or a surgeon specializing in hyperhidrosis is crucial to determine the best course of action.

5. Concerns About Recurrence and Compensatory Sweating: While ETS has a low recurrence rate, some patients do experience compensatory sweating. This side effect can vary in severity and location. It's essential to have a thorough discussion with your surgeon about the risks and benefits of surgery, as well as potential alternatives.

Conclusion
Hyperhidrosis can be a challenging condition to manage, but various treatment options are available. Non-surgical methods may provide relief for some, while others may find surgical interventions necessary for significant improvement. It is essential to consult with healthcare professionals who specialize in this area to explore the best options tailored to your specific needs. Your concerns about compensatory sweating and recurrence are valid and should be addressed in detail during your consultations.

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