HYPERHIDROSIS or excessive sweating

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WHAT IS Hyperhidrosis?

Axillary Hyperhidrosis, or excessive sweating in the armpits can cause embarrassing wet marks on shirts. Plantar Hyperhidrosis refers to excessive sweating of the feet and is a known cause of foot odour. Less commonly, patient may have excessive sweating of the trunk or thighs

Sweating is a natural body function needed for the regulation of body-temperature. There are five million sweat glands throughout the body and about 2/3 of these gland are located in the hands. The secretion of sweat is controlled by the sympathetic or (vegetative) nervous system. In some people (1% of the population), the nerves are over-stimulated and sweat is produced far greater than needed to keep a constant temperature. This condition is referred to as Hyperhidrosis. Excessive sweating may be episodic or continuous. Profuse sweating may be caused by warm weather, emotional stress, or occur without any reason. Hyperhidrosis may be part of an underlying medical condition (secondary Hyperhidrosis) or may be of unknown cause (primary Hyperhidrosis). In general, secondary Hyperhidrosis involves the entire body. Diseases or medical conditions causing secondary Hyperhidrosis include hyperthyroidism, endocrine treatment for malignant diseases, psychiatric disorders, obesity and menopause. Primary Hyperhidrosis, or sweating without known cause is also termed idiopathic or essential Hyperhidrosis. This is a much more common condition than secondary Hyperhidrosis and may occur in one or several location s of the body. The hands, feet and armpits are the most common locations. The condition usually starts during adolescence and is lifelong. Nervousness and anxiety can precipitate excessive sweating.


Facial sweat may be so profuse that it causes the person to be insecure or anxious. The person may appear overly nervous when this is not the case. Patients may also experience excessive facial blushing. Sweaty hands is usually the most distressing manifestation of primary Hyperhidrosis. The amount of hand sweating varies from moisture to dripping. Many patients report that their hands also feel cold. Because our hands are exposed in social and professional settings, many patients with Hyperhidrosis are self conscious and may avoid social contact. They may be reluctant to shake hands, handle paperwork, etc . Patients have even been embarrassed to hold the han ds of those they love.

Axillary Hyperhidrosis, or excessive sweating in the armpits can cause embarrassing wet marks on shirts. Plantar Hyperhidrosis refers to excessive sweating of the feet and is a known cause of foot odour. Less commonly, patient may have excessive sweating of the trunk or thighs.

TREATMENT OF Hyperhidrosis

In secondary Hyperhidrosis, the underlying medical condition should be treate d first. For example, patients with hyperthyroidism should have treatment directed at their endocrine disease. Those patients with psychiatric diseases such as anxiety disorders should seek pyschiatric care. Treatment options for primary Hyperhidrosis include antiperspirants, iontophoresis, drugs and botulinum toxin injections and surgery.


It is the simplest treatment and is usually recommended first. The most effective agent is aluminium chloride. This treatment works for patients with light to moderate Hyperhidrosis.


Botulinum toxin is a poison that interferes with nerve conduction. This toxin is produced by the bacteria Chlostridium Botolinum and works by interfering with the effect of the neuro-transmitter substance acethylcholine at the nerve synapses. In low doses, the toxin may be injected in the face or neck to paralyse local muscles to prevent wrinkles or treat muscular spasms. It may also be used to treat Hyperhidrosis by paralysing the sympathetic nerves that cause sweating by injecting the toxin in the axilla or hands. It works well for axillary and palmar Hyperhidrosis. The treatment has a good success rate and can be done as a outpatient


Iontophoresis is a second line treatment if antiperspirants fail. This treatment consists of applying low intensity electric current to the hands or feet immersed in an electrolyte solution. The procedure has to be repeated regularly several times/week. The results vary, but many patients believe it is too time consuming and expensive. It is difficult or impossible to treat axillary or facial Hyperhidrosis with this method.


Various drugs may affect sweating, but in general are not recommended for the treatment of Hyperhidrosis because of side affects including dry mouth, blurred vision and sedation.


Endoscopic thoracic sympathectomy cures Hyperhidrosis. Surgery is performed by inserting a miniature camera and i instruments into the chest through small stab wounds similar to that used for knee arthroscopy. The vascular surgeon cuts or clip the sympathetic nerves of the  ganglion with magnification and illumination provided by the camera. The surgery lasts an hour. The procedure is performed on an out-patient basis and most patients return to work and regular physical activity within one week. The endoscopic technique is very safe and is curative in 98% of patients. The procedure is performed bilateraly in the same session.


How effective is surgery? The effect of the operation is immediately evident. Upon awaking from the anaesthesia the hands are warm and dry. The effect on facial sweating and/or blushing will be noticed in stressful situations which previously usually would cause blushing. The results of the procedure has been investigated after several years and patient have been asked  to assess their symptoms on a scale from 0 to 10 where 0=no symptom at all and 10= the most severe symptom. The results ( mean) are provided in the table below.


Who cannot have this surgery? Those patients with previous chest surgery or significant pulmonary disease may not be candidates. Patients at risk for severe side effects should also not be operated

Should I have surgery? That is a individual decision based upon how much Hyperhidrosis affects quality of life and understanding the risks and benefits of surgery. New surgical techniques have dramatically reduced the discomfort and healing time for those patients considering sympathectomy.

What are the risks of surgery? Risks of surgery include infection, blood loss and injury to structures in the chest including the lung and nervous tissue. These complications are extremely rare, but not nil. The major neurological risk of the procedure is a Horners syndrome. Patients wit h a Horners syndrome will notice a lazy eyelid and a small pupiland impaired vision. This syndrome is caused by injury to the T-1 sympathetic nerves, located just above the T-2 ganglion and which innervate the eyelid muscles and pupil. 

What are side effects of surgery? Patients may experience compensatory sweating of the chest, abdomen, thighs and legs. This may occur in up to 80% of patients. 2% of these patients develop incapacitating Compensatory Sweating. A list of all possible side effects can be seen at   http://home.swipnet.se/sympatiska/

Clipping or cutting? Clipping is safer than cutting because there is no dispersion of heat, which could damage the stellate Ganglion and cause Horner syndrom. The clip can also be removed in case of severe compensatory sweating or postoperative Horner

T2, T3 or T4? This indicates the hight of the clipping or cutting, T2 stands for the second thoracic ganglion. The clipping in this case is done above and below the second ganglion or only above (to reduce trauma to the nerve). T2 sympathectomy is required by FB and facial sweating. T3 is useful by hand sweating and armpits sweating. As a rule the higher the sympatic trunk is interrupted more compensatory sweating is present, but rarer are recurrences. The height of the cut or clip should be discussed with the patient

Is ETS reversible? Yes. ETS is reversible. If ETS is performed with a Clip (ESB), this can be removed by a similar endoscopic procedure. IF the sympathetic trunk has been cut or  gangliectomy or cauterisation of the chain has been performed a nerv transplant procedure is necessary. The sural nerve is harvested from the ankle region or form the intercostalspace and implanted in the gap between the two cut ends und secure by fibrin glue. This is done endoscopically.

How effective is reversal?  In case of ETS-C the clip can be removed and CS and the thermoregulatory function will improve. The chances of succsess are higher if the clip is removed soon after surgery. In case of nerve transplant the jury is still out, there are no serious  statistics available,  but there is a growing body of anecdotal evidence suggesting a partial improvment after reconstruction 

How do you treat Horner-syndrome: 2/3 of Horner-syndromes improve without treatment after 5-6 months. The rest need corrective surgery of the Eyelid. Results are not always satisfactory.

What is the problem with ETS? ETS is a very effective way to treat hyperhidrosis and FB in the vast majority of the cases, but  a small group of patients have devastating effects. Unfortunately, we do not know who  these patients are before we operate. There is some evidence that this patients are muscular or obese (BMI >30), older, male  and on medication and have T2 sympathectomies.. There is no resarch at all on this subject and no scientific sound  evidence is available.   More research is needed. The extent of surgery is  also a very important factor: less invasive the surgery, less side effects. Extensive surgery or burning causesnerve scaring, which may behave like epilepsy of the autonomous nervous system and cause the well known devastating side effects.


Contact Information

Dr Alberto Giudiceandrea Consulta    Dr. Giudiceandrea Alberto, general and vascular surgeon      


Hospital: Clinica Valle Giulia Via G De Notaris 2/b, Rome, Italy

Hospital: Clinica Sant'Anna, via del Franzone, Brescia

tel ++39 3333740186

Email form: Click here, if you have any questions, fill in the form and you will get a answer

Curriculum vitae


Do you have more questions or are you interested in the recent literature or do you want to know the evidenced based facts? Go to the following webpages:


Presentations at the 4th International Symposium on Sympathetic Surgery in Tampere 2001 

Presentations at the 3rd International Symposium on Symathetic Surgery in Japan in 1999

SYMPATHETIC ASSOCIATION FfSo People disabled by sympathectomies