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Robotic selective thoracic sympathectomy for hyperhidrosis: refined technique and anatomical variation

Multimed Man Cardiothorac Surg. 2026 Oct 14;2026. doi: 10.1510/mmcts.2026.094.

ABSTRACT

Primary hyperhidrosis substantially impairs quality of life. Conventional sympathectomy risks compensatory hyperhidrosis through trunk disruption, whilst selective sympathectomy preserves the trunk while dividing preganglionic and postganglionic fibres. We describe a technique refinement and a previously undescribed anatomical variant. A 23-year-old man had severe refractory palmar, axillary, plantar and gustatory hyperhidrosis (SSDS 4) profoundly affecting his confidence, social functioning and mental wellbeing, despite conservative management. He underwent staged bilateral robotic selective dorsal thoracic sympathectomy. Preganglionic and postganglionic fibres were divided from the top of T2 to T4 with trunk preservation. Refinements included resection from the top of the second rib, minimal diathermy with sharp dissection and non-touch technique using Maryland bipolar forceps. On the right, a postganglionic ramus ascending retrogradely from a displaced T3 ganglion into the third intercostal space was identified, previously undescribed in the literature, requiring dissection across the fourth rib to prevent hypothesized residual axillary hyperhidrosis. Both stages were completed 1 month apart, drain-free, with next-day discharge. There was complete symptom resolution, no Horner’s syndrome and no compensatory hyperhidrosis at follow-up.

PMID:42872462 | DOI:10.1510/mmcts.2026.094

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Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: ten-year clinical outcomes and a phenomenology-informed interpretation of body experience

Psychol Health Med. 2026 Oct 12:1-21. doi: 10.1080/13548506.2026.2746787. Online ahead of print.

ABSTRACT

Primary focal hyperhidrosis (PFH) is a chronic condition of excessive sweating disproportionate to thermoregulatory need, with substantial social and occupational burden. We evaluated outcomes of endoscopic thoracic sympathectomy (ETS)-symptom severity, quality of life, satisfaction, compensatory hyperhidrosis (CH), and recurrence-and interpreted dissatisfaction among patients who developed CH through a phenomenological lens. This retrospective single-centre cohort study included 72 patients who underwent ETS for PFH between January 2013 and December 2021, assessed preoperatively and at years one and five using the HDSS, DLQI, and Gillespie satisfaction scale. Sympathectomy level, technique, CH, recurrence, and psychosocial avoidance behaviours were recorded. Normality was rejected on Shapiro-Wilk testing; Wilcoxon signed-rank, Mann-Whitney U, chi-square, and Fisher’s exact tests were applied, with effect sizes as rank-biserial correlation (r) and Cramér’s V. The study received ethics approval (3 June 2026-39804) and adheres to the STROBE checklist. The cohort comprised 72 patients (44 male/28 female; mean age 22.8 ± 5.2 years; disease duration 7.3 ± 2.8 years). Palmar localisation predominated (63.9%); 90.3% avoided handshaking preoperatively. Mean HDSS declined from 3.29 ± 0.74 to 1.65 ± 0.96 at year five (p<0.001;r = 0.83); 61.5% reached HDSS = 1. Mean DLQI fell from 3.83 ± 0.67 to 1.94 ± 1.07 (p<0.001;r = 0.84); DLQI≥4 dropped from 68.1% to 7.7%. Five-year satisfaction was 76.6%. CH developed in 13 patients (18.1%), graded by level-T2 72.7%, T3 10.4%, T3-T4 0%(χ2 = 26.98;p<0.001; V = 0.61). Five-year DLQI was 3.23 ± 1.17 with CH versus 1.62 ± 0.77 without (p<0.001;r = 0.73); 84.6% of CH patients were undecided or regretful versus 7.8% without (p<0.001). Recurrence was 5.6%. ETS achieves durable symptom control and well-preserved long-term satisfaction in PFH. Marked dissatisfaction among patients who develop CH indicates that body-related awareness and social functioning are, for a meaningful subset, as decisive as physiological control. T2 sympathectomy should be reserved for clear anatomical indications, and informed consent should address the lived significance of CH beyond statistical risk disclosure.

PMID:42861922 | DOI:10.1080/13548506.2026.2746787

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Radiofrequency Ablation for Refractory Palmar and Plantar Hyperhidrosis: A Case Report

Anesth Pain Med. 2026 Feb 28;16(1):e172975. doi: 10.5812/aapm-172975. eCollection 2026 Feb 28.

ABSTRACT

INTRODUCTION: Palmar and plantar hyperhidrosis (PH) is characterized by sweat production that far exceeds thermoregulatory needs and often has substantial effects on daily functioning, social interaction, and mental health. The condition results from sympathetically mediated overstimulation of the eccrine glands, which are innervated by unmyelinated cholinergic C-type fibers. Radiofrequency ablation (RFA) offers a minimally invasive approach to symptom control in refractory PH through heat-mediated disruption of these sympathetic fibers. Reports describing staged upper- and lower-limb RFA for combined palmar and plantar disease in a single patient remain uncommon; this is the primary reason for presenting this case.

CASE PRESENTATION: A 21-year-old man (American Society of Anesthesiologists physical status I) presented with a 10-year history of progressive palmar and plantar hyperhidrosis that had not shown durable responses to conservative or prior interventional treatment. He used topical aluminum chloride for 2 months without meaningful benefit and subsequently underwent 2 sessions of palmar botulinum toxin injections 5 months apart, which reduced palmar sweating by an estimated 50 – 60% for approximately 2 months per session; the lower limbs were not treated. Eighteen months before the current admission, he underwent RFA of the right thoracic sympathetic chain at another center. This produced approximately 80% improvement in palmar sweating, although sweating persisted along the ulnar nerve distribution; the benefit lasted only approximately 4 months, after which symptoms recurred to baseline. During the present admission, staged RFA was performed bilaterally at L3, with different lower-limb protocols selected in advance based on the prior treatment response and the greater severity of plantar sweating on the left. Seven days later, bilateral RFA was performed at T3. At the 2-week, 1-month, and 7-month follow-up visits, the patient reported no compensatory sweating or change in cutaneous sensation. By his own assessment, overall sweating of the palms and soles was reduced by approximately 90% from baseline, with a satisfaction score of 9/10 and subjectively improved quality of life.

CONCLUSIONS: Staged RFA targeting both the thoracic and lumbar sympathetic chains appears to be a reasonably safe palliative option for patients with refractory combined palmar and plantar hyperhidrosis, with a more favorable complication profile than surgical sympathectomy. This case is considered reportable because it involves combined, staged treatment of both the upper and lower limbs in a single patient.

PMID:42763681 | PMC:PMC13589454 | DOI:10.5812/aapm-172975

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Primary Hyperhidrosis: A Review of Epidemiology, Pathophysiology and Management

Acta Derm Venereol. 2026 Sep 16;106. doi: 10.2340/actadv.v106.adv-2026-0770.

ABSTRACT

Primary hyperhidrosis is termed as excessive sweating exceeding the physiological needs of thermoregulation. This review provides an updated overview focusing on epidemiology, quality of life, pathophysiology, economic impacts, diagnostic approaches and current management strategies. A literature search was conducted in June 2026 across PubMed and the Cochrane Central Register of Controlled Trials. Additional references were identified through manual searches of relevant bibliographies. Reported prevalence of hyperhidrosis varied widely, likely reflecting differences in methodology and disease recognition. Primary hyperhidrosis is associated with autonomic dys-regulation involving sympathetic pathways. Emerging evidence suggests that molecular alterations in eccrine glands may represent secondary adap-tations to sustained cholinergic stimulation, while genetic variability in receptor expression may contribute to interindividual differences in disease severity. Hyperhidrosis has a strong negative impact on the economy and quality of life, adversely affecting both mental and physical health. Multiple treatment options are available, including topical therapies, systemic agents, device-based interventions, botulinum toxin injections, and surgery. Despite increasing recognition of the clinical burden, comprehensive economic evaluations remain limited, with indirect costs and long-term societal impact insufficiently characterized. In conclusion, primary hyperhidrosis imposes a substantial burden on affected individuals, requiring improved re-cognition, standardized diagnostic frameworks, and individualized management strategies supported by high-quality and longitudinal research.

PMID:42747166 | DOI:10.2340/actadv.v106.adv-2026-0770

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A 1% glycopyrronium bromide cream for topical treatment of severe primary axillary hyperhidrosis in adolescents: safety, local tolerability, systemic exposure and efficacy from an open-label phase II study

J Dtsch Dermatol Ges. 2026 Sep 15. doi: 10.1111/ddg.70469. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Primary axillary hyperhidrosis (PAHH) results from dysregulation of the autonomic nervous system and typically begins during puberty. Treatment options for adolescents remain limited. This open-label phase II study evaluated the safety, local tolerability, systemic exposure, and efficacy of 1% GPB cream over 8 weeks in adolescents with severe PAHH.

PATIENTS AND METHODS: A total of 42 adolescents (23 male [55%] and 19 female [45%]; aged 12-17 years) applied the cream once daily for the first 4 weeks and thereafter as needed (at least twice weekly but no more than once daily). The primary endpoints assessed adverse drug reactions (ADRs), local tolerability, and systemic glycopyrronium exposure. Changes in sweat production, PAHH severity, and quality of life were assessed in all patients.

RESULTS: Two patients experienced mild ADRs (dry eye and increased conjugated bilirubin in one patient each); no serious adverse events occurred. All 40 evaluable patients had a skin reaction score of 0 throughout treatment. Total sweat production decreased significantly from baseline to day 29 (p < 0.001) and day 57 (p < 0.001). Patient-rated hyperhidrosis severity (PRHS) and quality of life, assessed using the Children’s Dermatology Life Quality Index (CDLQI), also improved significantly at both time points (all p < 0.001).

CONCLUSIONS: 1% GPB cream showed favorable safety and tolerability and improved clinical outcomes in adolescents with severe PAHH, consistent with findings in adults.

PMID:42745527 | DOI:10.1111/ddg.70469

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Persistent Hyperhidrosis in the Psychiatric Setting: A Case Report

Cureus. 2026 Aug 11;18(8):e114349. doi: 10.7759/cureus.114349. eCollection 2026 Aug.

ABSTRACT

Hyperhidrosis, defined as excessive sweating beyond what is required for thermoregulation, is a recognized adverse effect of numerous medications, including several classes of psychotropic agents acting through different mechanisms. We present the case of a 43-year-old male with a complex psychiatric and medication history who developed persistent, drenching night sweats that continued despite multiple psychotropic medication adjustments and discontinuations. Alternative metabolic, infectious, endocrine, and substance-related causes were considered without identification of a clear etiology. This case highlights the difficulty of attributing hyperhidrosis to a single agent in patients with complex medication histories and emphasizes the importance of balancing symptom management with the continuation of necessary psychiatric treatment.

PMID:42725212 | PMC:PMC13561136 | DOI:10.7759/cureus.114349

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Efficacy and safety of rib-guided percutaneous thoracic sympathetic radiofrequency thermocoagulation at two different targets for primary palmar hyperhidrosis: a randomized controlled trial

Ann Med. 2026 Dec;58(1):2717461. doi: 10.1080/07853890.2026.2717461. Epub 2026 Aug 26.

ABSTRACT

OBJECTIVES: To compare the efficacy and safety of computed tomography-guided percutaneous thoracic sympathetic radiofrequency thermocoagulation (RFT) targeting the upper versus lateral margin of the fourth rib head for severe primary palmar hyperhidrosis (PPH).

METHODS: Patients with severe PPH were randomly divided into Group U (upper margin target) and Group L (lateral margin target). Outcome measures included 1-year recurrence rate, Hyperhidrosis Disease Severity Scale (HDSS), Dermatology Life Quality Index (DLQI), palm skin temperature, finger perfusion index (PI), compensatory hyperhidrosis and patient satisfaction.

RESULTS: Both groups (n = 55 each, 110 sides) successfully underwent RFT. No preprocedural PI differences were found (p > 0.05). Immediately post-RFT, PI in Group L was significantly higher than in Group U (left p = 0.025, right p = 0.013). No significant differences in HDSS grades were observed between groups before and at 1 day, 2 weeks, 1 month and 3 months post-procedure. However, at 6 and 12 months, Group L showed significantly lower HDSS grades (left p = 0.033 and 0.016; right p = 0.039 and 0.025) and lower DLQI scores (p = 0.037 and 0.024) than Group U. Patient satisfaction did not differ within 6 months, but Group L had significantly higher satisfaction at 12 months (p = 0.036).

CONCLUSIONS: Targeting the lateral margin of the fourth rib head for RFT achieved greater efficacy, better quality of life and higher patient satisfaction compared to the upper margin target.

PMID:42647852 | DOI:10.1080/07853890.2026.2717461

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Botulinum toxin A for primary axillary hyperhidrosis: a narrative review

J Med Life. 2026 Jun;19(6):420-425. doi: 10.25122/jml-2026-0005.

ABSTRACT

Primary axillary hyperhidrosis (PAH) markedly impairs psychosocial well-being and daily functioning. Botulinum toxin type A (BoNT-A) is widely used, both on- and off-label, to suppress eccrine sweating through presynaptic inhibition of acetylcholine release and temporary chemodenervation of cholinergic sympathetic fibers. This narrative review synthesizes published clinical evidence between 2000 and January 2025 regarding the efficacy, durability, safety, and quality-of-life outcomes of BoNT-A for PAH, with comparative consideration of toxin formulations, injection techniques, and device-based alternatives. Evidence from randomized trials, prospective cohorts, long-term observational studies, and meta-analyses consistently demonstrates that intradermal BoNT-A achieves substantial axillary sweat reduction, often exceeding 50-80%, with improvement of at least two grades on the Hyperhidrosis Disease Severity Scale and meaningful reductions in Dermatology Life Quality Index scores. Treatment effects typically persist for approximately 4-7 months per cycle and are associated with predominantly mild, localized adverse events. Comparative data indicate similar efficacy among onabotulinumtoxinA, incobotulinumtoxinA, and abobotulinumtoxinA when equivalent dosing and standardized mapping techniques are applied. Injection strategy, particularly multi-point intradermal delivery guided by starch-iodine mapping, influences coverage and durability. Energy-based modalities-including microwave thermolysis and fractional microneedle radiofrequency-reduce sweating via device-mediated thermal targeting of eccrine glands and show variable comparative outcomes versus intradermal BoNT-A in durability, downtime, and cost. Overall, BoNT-A remains a well-supported first-line injectable therapy for PAH refractory to topical treatment, while further head-to-head and cost-effectiveness studies remain warranted.

PMID:42602382 | PMC:PMC13474375 | DOI:10.25122/jml-2026-0005