Excessive hand sweating is the most common type of hyperhidrosis. It is caused by heightened activity in the sympathetic chain of nerves, part of the autonomous nervous system that involuntarily controls activities in the body. The sympathetic chain is located in the chest cavity.
Excessive hand sweating can range from mild to very severe, and may be genetic in origin. Sweaty palms usually begin early in childhood and can get worse in the late teenage years and early adulthood. It does not get better over time or go away with age. Most people with severe sweaty palms do not benefit from conservative treatment with medications, iontophoresis, or biofeedback, although health insurance companies may dictate that these remedies be tried first. For severe palmar hyperhidrosis, the best option may be a surgical procedure called endoscopic thoracic sympathectomy (ETS).
The most successful treatment for excessive sweating of the hands (palmar hyperhidrosis) is a minimally invasive procedure called endoscopic thoracic sympathectomy (or ETS). Our team is highly skilled in performing ETS and thorascopic procedures. The surgery is performed through two keyhole incisions (each about a quarter of an inch) made under the armpit. Using a telescope called a thoracoscope - a thin instrument with a light source and tiny fiberoptic camera attached - the surgeon views a magnified area to be operated upon.
Using special instruments placed inside the keyhole incisions, the surgeon selects sympathetic nerves or nerve ganglia (nerve terminals) in the chest and then cuts them, interrupting nerve impulses in the sweat glands. This does not harm the sympathetic nervous system because there is overlap in the functioning of the sympathetic chain of nerves. Because ETS is performed through small keyhole incisions rather than a large chest incision, there is no scarring, less pain, and a faster recovery. The entire surgery takes about one hour, and most patients go home later that day. There may be some soreness at the incision site and in the chest area, but the sutures are below the skin and they will dissolve. You can shower the following day and return to your job and normal activities within several days.
ETS is very effective. In most patients, it is a permanent procedure that should be considered for severe palmar hyperhidrosis only. Dr. Korst reports that at at least 98 percent of his patients with palmar hyperhidrosis have found relief from excessive sweating of the hands with ETS. Patients experience immediate relief; they wake up from surgery with warm dry hands. ETS also eliminates facial blushing and facial sweating in patients who also experience these problems. In rare occurrences, 1 to 2 percent of patients undergoing ETS, hand sweating may recur. Most of these recurrences are mild, but if they are severe, a repeat operation may be necessary.
Most patients from ages 10 to 65 can be treated with ETS. The surgery may not appropriate for those with cardio-respiratory illness, pleural disease, untreated thyroid disease, or excessive scarring of the chest. Our team will review your individual medical condition and unique needs and determine if you are a good candidate for ETS.
Palmar hyperhidrosis is considered a medical condition with serious physical and psychological complications when not treated. Therefore, ETS is usually covered by health insurance because it is considered a medical necessity, not a cosmetic procedure. However, your policy may require you to try more conservative methods first, such as medications or iontophoresis (see below). You should check with your individual health insurance coverage to determine your benefits.
Risks of Surgery
ETS is performed under general anesthesia and carries the risks of any surgical procedure: reactions to medications, bleeding, or infections. During ETS, the surgeon collapses the lung to enable him to see the sympathetic nerve. Collapsing a lung during surgery is routine in all types of thoracic surgical procedures and has no associated risks. When ETS is completed, the lung is reinflated. A small amount of air is left in the chest cavity (pneumothorax), but the air is reabsorbed within a few days and there are no long-term effects. In rare instances, bleeding into the chest may occur (hemothorax). If the blood does not resolve on its own, a repeat thoracoscopic procedure to remove blood clots from the chest cavity may be needed.
Side Effects of ETS
The most common side effect of ETS is compensatory sweating - excessive sweating of the back, abdomen, thighs, and legs. About 70 percent of patients who undergo ETS will experience compensatory sweating to some degree. Patients who only have palmar hyperhidrosis are the least likely to have significant compensatory sweating following ETS. When ETS is performed for axillary hyperhidrosis, the risk of compensatory sweating increases. Generally, everything from the nipple line up will be dry from the ETS procedure. Compensatory sweating is tolerated well by most patients and is, in most cases, viewed as far more manageable than their initial problem of hyperhidrosis. The medication Robinol has been effective in some cases in decreasing generalized body sweating.
The incidence of developing Horner's Syndrome - marked by droopy eyelids, constricted pupils, and the absence of face sweating - is very rare (about 0.3%). It can occur if the sympathetic nerve near the T1 level is also disrupted. The risk of Horner's syndrome is highest in patients who undergo ETS for facial hyperhidrosis and/or blushing, since the sympathetic nerve chain is cut closer to the T1 level compared with ETS for other types of hyperhidrosis.
Gustatory sweating - sweating of the face while eating or smelling certain types of foods - happens in a small number of patients following ETS, but it is usually not a major problem.
Neuritis and Neuralgia
Neuritis and neuralgia, which is non-specific pain in the back between the shoulder blades, occurs in a very small number of patients and is secondary to irritation of the nerve endings. This condition usually stops on its own and is rarely severe or permanent. It can be treated with non-steroidal anti-inflammatory drugs, such as Motrin.
Brachial Plexus Injury
This condition, marked by weakness or paralysis of the upper extremities, is extremely rare and is caused by an injury to the spinal nerves.
Decreased Heart Rate
Many patients experience a 10% drop in heart rate after surgery, but this condition has not been demonstrated to affect endurance and tolerance of exercise. In fact, ETS seems to benefit patients with certain arrhythmias of the heart. Nevertheless, competitive athletes who depend on the maximization of their heart rate need to consider this possible side effect more closely than others.
Dry Facial Skin
After ETS, some patients notice dry skin in their face, neck, and scalp. It can be treated with moisturizing creams. Drying of the skin often improves acne in many patients, which is a "side effect" with important benefits for many young adults and teenagers.
Other Treatments for Sweaty Palms
This treatment involves placing the hands in two pails of water that contain a conductor. A device (brand names Drionic®, Idrostar, MD-1A) applies a low electric current to the hands. As the current passes through each hand, minerals in the water clog the sweat glands, limiting the amount of sweat released. Each session lasts 20 minutes and is repeated four to six times per week. Frequent treatments are necessary. Some people have experienced good results with this treatment while others see no effect.
There are no medications for the specific treatment of primary hyperhidrosis. However, the condition can be treated with some success with systemic anticholinergics. Ditropan® (generic name: oxybutynin) is one that has been the most promising, but the dry mouth and drowsiness associated with it cannot be tolerated by some patients. Robinul® (generic name: glycopyrrolate) is sometimes effective but also causes dry mouth or a dry throat. These two medications also can cause dilated pupils, constipation, urinary retention, and heart palpitation. Beta-blockers (Inderal) have systemic anti-sympathetic effects that are helpful in decreasing the body's sympathetic response. They have been useful in some cases of stress-related hyperhidrosis. They also decrease palpitation and tremors and are mostly useful when taken two hours before a stressful situation. Anti-depressants (Zoloft®) and anti-anxiety medications can be effective. Depression does not cause hyperhidrosis, but hyperhidrosis can cause depression. Probanthine® (generic name: propantheline bromide), which is often used to treat high blood pressure and some arrhythmias, causes a systemic decrease in sympathetic response. It should only be administered after a patient undergoes a thorough physical examination.
Topical agents, such as Drysol (or other antiperspirant brands of aluminum chloride with ethyl alcohol) or Odaban can also be used for palmar hyperhidrosis. These agents are generally applied to dry hands at night. However, such topical agents are generally not effective for palmar hyperhidrosis.
Laser ablation is not effective in controlling primary hyperhidrosis.
Hyperhidrosis can be aggravated by obesity, so weight loss can help. However, most people with hyperhidrosis do not sweat excessively due to obesity.
Relaxation techniques, hypnosis, and biofeedback offer limited success for sweaty palms.