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Hyperhidrosis is characterized by excessive sweating that occurs in up to 1% of the population. The excessive sweating can occur in the hands (palmar hyperhidrosis), in the armpits (axillary hyperhidrosis), in the feet (plantar hyperhidrosis) or in the face. No one understands the exact cause of this excessive sweating in specific individuals, but it is known that sweating is controlled by the sympathetic nervous system.

Although physicians are researching the cause of hyperhidrosis, it is unknown why excessive sweating occurs in certain individuals. We are uncertain whether it is the over activity of the sympathetic nervous chain or the sweat glands. As you know, hyperhidrosis, excessive sweating, can hamper daily activities. It is sometimes brought on by stress, emotion, or exercise, but can also occur spontaneously.

The initial treatment for hyperhidrosis is usually medical. There are ointments that are astringents that dry up the sweat glands. Another treatment is iontopheresis. This consists of electrical stimulation to the hands. Patients place their hands in a bath through which an electrical current is passed. This treatment stuns the sweat glands and can decrease the secretion of sweat for periods of 6 hours to one week. One of the newest treatments proposed is the injection of botulinum toxin (Botox) into the area of excessive sweating. The toxin affects nerve endings to decrease the transmission of the nerve impulses to the sweat glands. This results in decreased sweating. It generally requires several injections in the palms or underarms and it remains effective for one to six months. Repeated injections are nearly always required to maintain an adequate level of dryness.

In addition, many medicines, including sedatives, have been utilized with varying success. A family practitioner or internist often begins the initial treatment for hyperhidrosis. Cases not responding to simple treatment regimens are often then referred to a dermatologist or a neurologist.

The surgical treatment of hyperhidrosis involves severing or clipping a specific portion of the main sympathetic nerve. As previously stated the sympathetic nerves are separate from the somatic (voluntary) nerves that control sensation and motor function. The sympathetic nerve "chain" is located next to the ribs in the chest. The branches of the sympathetic "chain" originate from between vertebral bodies of the spine and end in a bundle of cells called a ganglion. There are ganglions at each vertebral level of the spine and all these ganglions are attached one to another longitudinally to form the "sympathetic chain." A sympathetic nerve branch arises from these ganglions and travels to innervate blood vessels and sweat glands in the body. The operation entails controlling the specific ganglion that causes sweating in the arm and the axilla.

In the past, a moderate to large sized incision in the chest was required to expose the sympathetic chain. Recent technology allows a less invasive method known as endoscopic thoracic sympathectomy (ETS). Although general anesthesia is required, this is otherwise a minimally invasive procedure. Once asleep, two small (3 mm) incisions are made below the armpit. Through these holes, a videoscope is utilized to view the sympathetic chain. Through the other incisions, surgeons place instruments to cauterize or clip the specific ganglions (sympathectomy). After confirmation of adequate smpathectomy, the incisions are closed with a sterile super glue. Thoracic surgeons have extensive experience with the intrathoracic anatomy and manipulation of the lungs, making the procedure very safe. Rarely (less than 1 in 100 times), a small tube is left inside the chest to allow evacuation of air; however, this is usually removed within hours of the surgery. After one side is completed, the opposite side is addressed and the identical procedure is performed. Typically, the patient may go home the same day after recuperating from anesthesia. If a chest tube is needed it is usually removed the next morning and the patient is allowed to go home. As with every operation, there is some pain and most patients will require some mild oral pain medication for a period of 7-10 days following surgery.

There are some possible side effects of the operation. The most common is compensatory sweating, which may occur in up to 50-60% of patients. As you recall, sweating is one form of regulating the body's heat. This operation prevents or reduces sweating in the upper chest, arms, and hands; and patients may notice a greater amount of sweating elsewhere on their body in order to compensate. This is called "compensatory sweating" and can occur on the abdomen, back, buttocks, thighs, or feet. Most people tolerate this, but occasionally (5-10% of patients) it can be severe enough to interfere with the patient's lifestyle.

The Division of Thoracic surgery at the University of Florida has created the Hyperhidrosis Center. It is a core group of multidisciplinary individuals with an interest and special skill in the surgical treatment of hyperhidrosis. Dr. Charles Klodell is an Assistant Professor with the Division of Thoracic surgery, and began performing the ETS procedure in 1998. He joined the faculty at the University of Florida in 2002 and continues to have a strong clinical interest in the treatment of hyperhidrosis. Interested patients or physicians wishing to make a referral may contact the Hyperhidrosis Center at 352-273-5507 or email NoSweat@surgery.ufl.edu.

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