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A prospective controlled randomized multicenter study to evaluate the severity of compensatory sweating after one-stage bilateral thoracic sympathectomy versus unilateral thoracic sympathectomy of the dominant side

Clinics (Sao Paulo). 2026 Nov 4;81:101219. doi: 10.1016/j.clinsp.2026.101219. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare, in a Brazilian population, the clinical efficacy, Quality-of-Life (QoL) impact, and severity of compensatory sweating (CS; new excessive sweating in previously unaffected body regions) after one-stage Bilateral Thoracic Sympathectomy (BTS) versus Unilateral Sympathectomy on the dominant side (UniS), with additional assessment of patients who later underwent contralateral surgery (two-stage bilateral Sympathectomy, 2stS).

METHODS: This was a prospective, randomized, controlled, multicenter trial conducted across 11 Brazilian centers and included 163 adults with primary palmar hyperhidrosis. Participants were randomized 1:1 to BTS or UniS. From 6-months onward, UniS patients could elect contralateral sympathectomy. Sweating severity was assessed using the Hyperhidrosis Disease Severity Scale (HDSS) across predefined anatomical sites, and QoL was measured with the HidroQOL and Horn questionnaires. CS was defined as new postoperative sweating in previously unaffected areas (preoperative HDSS = 1) and graded by the magnitude of HDSS increase.

RESULTS: Baseline characteristics were generally comparable between groups. Improvement in the operated dominant hand was similar after BTS and UniS, whereas control of the non-operated hand favored BTS. In the UniS group, spontaneous contralateral improvement occurred in approximately 1 in 7 untreated hands. The proportion of patients without CS was similar in both groups (approximately 25%), but severe CS was more frequent after BTS than after UniS (40.4%vs. 21.0%; nominal, unadjusted p = 0.0344), an absolute difference of 19.4 percentage points. QoL improved in both groups, with larger and more sustained reductions in Horn and HidroQOL scores after BTS (p < 0.001). Thirty-two UniS patients underwent contralateral completion (40.0% of the randomized UniS group); post-completion outcome data were available for 18- at 8-months and 16- at 12-months. In this selected cohort, contralateral surgery produced additional HDSS and QoL improvement. CS was reassessed in 16 patients and occurred in 9 (56.2%; exact 95% CI 29.9%‒80.2%), with eight of nine cases classified as mild.

CONCLUSION: BTS provides more complete bilateral symptom control and greater QoL improvement, but at the cost of more severe CS. UniS offers excellent control on the treated side, reduces the risk of severe CS, and supports a staged strategy in which many patients avoid a second procedure; when needed, contralateral completion can restore additional clinical and QoL gains.

PMID:42981801 | DOI:10.1016/j.clinsp.2026.101219

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Prevalence of Hyperhidrosis: An Australian Population Study

Australas J Dermatol. 2026 Oct 30. doi: 10.1111/ajd.70224. Online ahead of print.

ABSTRACT

Hyperhidrosis is a common but under-recognised condition and this study aimed to determine its prevalence, clinical characteristics and healthcare utilisation among Australian adults. In a cross-sectional, population-based survey of 3000 Australian adults, 156 reported excessive or abnormal sweating, with 65% reporting severe disease, while younger age and student status were independently associated with hyperhidrosis. Despite the substantial burden of disease, only 49% had consulted a healthcare professional and 27% had received a formal diagnosis, highlighting a significant gap in recognition and healthcare engagement and the need for greater awareness and earlier diagnosis.

PMID:42960527 | DOI:10.1111/ajd.70224

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Quality of life before and after sympathectomy in primary hyperhidrosis: a recall-based paired analysis of 94 patients

Front Surg. 2026 Oct 15;13:1996976. doi: 10.3389/fsurg.2026.1996976. eCollection 2026.

ABSTRACT

OBJECTIVES: Primary hyperhidrosis substantially impairs quality of life. Sympathectomy is an established treatment for severe focal hyperhidrosis; however, patient-reported outcomes in Arab populations remain limited. This study evaluated recalled preoperative and current postoperative quality of life after sympathectomy using validated Arabic instruments.

METHODS: We conducted a secondary, recall-based paired analysis of a cross-sectional survey of 94 participants with primary hyperhidrosis who reported having undergone bilateral sympathectomy. Participants completed an Arabic electronic survey between May 2024 and April 2025. Current postoperative quality-of-life scores were compared with retrospectively recalled preoperative scores using the Arabic Hyperhidrosis Quality of Life Index (HidroQoL©); severity was assessed using the Arabic Hyperhidrosis Disease Severity Scale. Wilcoxon signed-rank tests were primary; paired t tests were sensitivity analyses.

RESULTS: The mean participant age was 30.7 ± 8.9 years, and 63.8% were men. At the recalled preoperative assessment, 55 participants (58.5%) reported Grade 4 disease severity. All 94 participants provided complete paired data. The mean daily-life score decreased from 8.5 ± 2.8 to 4.9 ± 4.5 [mean paired change -3.6; 95% confidence interval (CI) -4.5 to -2.8; dz = -0.88]. The mean psychosocial score decreased from 16.9 ± 5.5 to 8.8 ± 8.7 (-8.1; 95% CI -9.7 to -6.4; dz = -0.97). The total score decreased from 25.4 ± 7.5 to 13.7 ± 12.8 (-11.7; 95% CI -14.1 to -9.3; dz = -0.98); all p < 0.001. Thirteen participants (13.8%) reported a higher total score after surgery.

CONCLUSIONS: Participants reported substantially lower hyperhidrosis-related daily-life and psychosocial impairment after sympathectomy. Recall bias may affect the magnitude and direction of these differences, which do not establish causal treatment effects. Prospective studies incorporating true preoperative baseline assessment, operative details, compensatory sweating, and longer follow-up are needed to confirm the magnitude and durability of these improvements.

PMID:42959167 | PMC:PMC13716772 | DOI:10.3389/fsurg.2026.1996976

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Management of Craniofacial Hyperhidrosis with Botulinum Toxin: A Systematic Review

Skin Appendage Disord. 2026 Sep 25. doi: 10.1159/sad/aesag012. Online ahead of print.

ABSTRACT

INTRODUCTION: Treatment of craniofacial hyperhidrosis (CFH) is challenging because of the anatomical characteristics of the head and face. Although topical anticholinergics are generally considered first-line therapy, botulinum toxin has emerged as an effective option, while evidence remains more limited than for axillary hyperhidrosis. The objective of this study is to systematically review current evidence on the efficacy and safety of botulinum toxin in the treatment of CFH.

METHODS: Clinical studies evaluating different types of botulinum toxin type A (BoNT-A) and type B (BoNT-B) for CFH were reviewed, focusing on treatment efficacy, onset of response, anatomical sites and safety.

RESULTS: BoNT-A was the most consistently studied formulation and demonstrated substantial improvement of CFH. The duration of response generally ranged from 4 to 9 months, with more recent cohorts reporting efficacy lasting up to 12 months. Onset of action typically occurred within 1-2 weeks. The forehead and scalp were the most frequently treated sites, followed by gustatory and occipital regions. BoNT-B also produced significant reductions in sweating and improvements in quality of life.

CONCLUSION: Botulinum toxin appears to be an effective and safe treatment for CFH. Long-term studies are needed to establish the optimal toxin type, administration technique and retreatment interval.

PMID:42923985 | PMC:PMC13688397 | DOI:10.1159/sad/aesag012

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Bilateral R2 sympathetic surgery for craniofacial hyperhidrosis: a 10-year retrospective cohort study on long-term outcomes and development of a prognostic predictive model

Surg Endosc. 2026 Oct 20. doi: 10.1007/s00464-026-13521-x. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the long-term efficacy and safety of bilateral R2 sympathetic surgery for CFH, to characterize the 10-year longitudinal trajectory of postoperative CH and recurrence, and to identify clinically accessible predictors of CH and postoperative satisfaction that may assist in preoperative risk communication. Preliminary nomograms were developed and internally validated using the area under the curve (AUC), calibration plots, sensitivity, and specificity.

MATERIALS AND METHODS: A total of 127 patients who underwent bilateral R2 sympathetic surgery for CFH between April 2013 and April 2023 were retrospectively analyzed. Baseline characteristics, operative details, and follow-up outcomes were extracted from medical records and structured telephone interviews. Predictive features were selected using least absolute shrinkage and selection operator (LASSO) regression. Cox proportional hazards and multivariate logistic regression models were subsequently applied to identify independent predictors of CH and satisfaction, respectively. Nomograms were developed and internally validated using the area under the receiver operating characteristic curve (AUC), calibration plots, sensitivity, and specificity.

RESULTS: All patients achieved immediate resolution of craniofacial sweating, accompanied by a significant postoperative heart rate reduction (84.8 ± 11.68 → 72.17 ± 7.54 bpm, P < 0.001). Severe CH (grade IV) developed in 70.1% of patients, predominantly involving the thoracoabdominal (84.3%) and thigh (54.3%) regions. Cox regression identified preoperative heart rate > 79.5 bpm (HR = 2.46, 95% CI 1.61-3.75, P = 0.0002) and sympathetic clamping (HR = 5.69, 95% CI 3.03-10.67, P = 0.001) as independent risk factors for severe CH. Logistic regression showed that lower preoperative thoracoabdominal sweating was associated with higher postoperative satisfaction (OR = 0.05, 95% CI 0.01-0.23, P = 0.001). The nomograms demonstrated adequate discrimination and calibration.

CONCLUSION: Bilateral R2 sympathetic surgery achieves rapid and durable relief of craniofacial hyperhidrosis with sustained high satisfaction over 10 years. Beyond confirming efficacy, the extended follow-up uniquely demonstrates that CH severity stabilizes within the first postoperative year and does not worsen over time-a critical finding for patient reassurance. Preoperative resting heart rate > 79.5 bpm and the use of sympathetic clamping independently predict severe CH, whereas lower baseline thoracoabdominal sweating predicts superior satisfaction. Although the proposed nomograms require external validation before routine adoption, they offer a practical, individualized reference for preoperative risk communication and, combined with the intraoperative choice of electrocautery, support a dual-phase strategy for optimizing surgical outcomes in CFH patients.

PMID:42902000 | DOI:10.1007/s00464-026-13521-x

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Treatment Satisfaction and Patterns Among Primary Hyperhidrosis Patients

J Dermatol. 2026 Oct 19. doi: 10.1111/1346-8138.70539. Online ahead of print.

ABSTRACT

Primary hyperhidrosis can substantially impair daily activities and psychosocial well-being. This single-center cross-sectional questionnaire study examined treatment use and factors associated with treatment satisfaction among 92 patients with primary hyperhidrosis recruited by treating physicians at a single clinic between 2024 and 2025. Treatment use was analyzed at the patient-treatment level using logistic regression with patient-level clustering. Factors associated with treatment satisfaction were evaluated using generalized estimating equation logistic regression, and sensitivity analyses applied alternative satisfaction thresholds. Patient-reported sweat reduction was the factor most consistently associated with treatment satisfaction. This association remained evident in adjusted models and sensitivity analyses. In contrast, time to treatment effect, hyperhidrosis disease severity scale score, sex, age group, treatment-related adverse events, treatment modality, and affected site showed no statistically significant or consistent associations with satisfaction. Sweat reduction and satisfaction wasn’t completely concordant; some observations indicated satisfaction despite poor sweat reduction, whereas dissatisfaction despite favorable sweat reduction was rare. Treatment frequency showed no consistent association with satisfaction, and treatment duration differed only under one strict definition of satisfaction. Although affected site was not independently associated with satisfaction in the regression models, descriptive satisfaction rates varied across body-site and treatment-modality combinations. Patient-reported sweat reduction did not fully explain treatment satisfaction. Treatment benefit should therefore be assessed comprehensively by considering perceived sweat reduction, treatment burden, and broader clinical context.

PMID:42897084 | DOI:10.1111/1346-8138.70539

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Topical oxybutynin antiperspirant for axillary hyperhidrosis: a phase IIb PROBE design clinical trial (TODAY trial)

J Vasc Bras. 2026 Sep 14;25:e20250065. doi: 10.1590/1677-5449.20250065. eCollection 2026.

ABSTRACT

BACKGROUND: Primary hyperhidrosis is a chronic condition with limited therapeutic options.

OBJECTIVES: To evaluate the impact of 10% oxybutynin spray on axillary hyperhidrosis, considering both its local and systemic effects, in terms of Hyperhidrosis Disease Severity Scale (HDSS) outcomes for hyperhidrosis of the axilla and eight additional sites.

METHODS: Prospective phase II PROBE design trial. Adult patients with axillary hyperhidrosis were randomized to receive a 10% oxybutynin topical spray, oral oxybutynin, or placebo spray for 35 days. Efficacy was evaluated on day 35 using the HDSS and a hyperhidrosis-specific quality-of-life (QoL) assessment questionnaire.

RESULTS: 17 patients were randomized. No significant differences were observed in HDSS outcomes from baseline to day 35 in any of the three groups (2.5 [2 – 4], 4 [3 – 4], 3.5 [3 – 4], p= 0.207), although a trend to improvement was noted in both treatment groups. Significant improvement in the QoL questionnaire was observed from baseline to day 35 in the oxybutynin spray group (pre-intervention QoL: 78.5 [70 – 96] and post-intervention QoL: 38.5 [32 – 67], p = 0.031).

CONCLUSIONS: No differences were observed in the primary outcome. A significant improvement from baseline to day 35 was observed in the QoL questionnaire score for the oxybutynin spray group.

PMID:42890128 | PMC:PMC13671017 | DOI:10.1590/1677-5449.20250065

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Efficacy of Radiofrequency Combined with Chemical Sympatholysis in the Treatment of Primary Palmar Hyperhidrosis: A Retrospective Cohort Study

J Vasc Interv Radiol. 2026 Oct 14:109135. doi: 10.1016/j.jvir.2026.109135. Online ahead of print.

ABSTRACT

PURPOSE: To investigate and compare the efficacy and safety of radiofrequency thermocoagulation (RFT) and combined with chemical sympatholysis (RFT-CS) for the treatment of primary palmar hyperhidrosis (PPH) (Hyperhidrosis Disease Severity Scale [HDSS] grade III or IV).

MATERIALS AND METHODS: Patients who underwent computed tomography-guided percutaneous thoracic sympathetic neurolysis (TSN) for PPH were retrospectively analyzed and divided into two treatment regimens: RFT (group RFT, N = 60, 120 sides) and RFT combined with CS (group RFT-CS, N = 58, 116 sides).

RESULTS: At 1, 3, 6, 12, and 24 months, the number of sides with HDSS III/IV in the RFT group was 29, 32, 41, 47, and 56, respectively; in the RFT-CS group, 25, 31, 36, 40, and 45, with no statistically significant intergroup differences at any time point (all P ≥ .05). Overall recurrence rates rose from 3.0% at 1 month to 19.5% at 24 months, with no significant differences between groups at any time point (all P ≥ .05). The RFT-CS group had significantly higher compensatory hyperhidrosis (CH) rates at 12 months (62.1% vs. 56.7%; P = .012) and 24 months (58.6% vs. 50.0%; P = .014), and a higher incidence of thoracic neuralgia at 1 month (P = .023) and 3 months (P = .011).

CONCLUSION: Both of the TSN treatment modes are effective for the treatment of severe PPH. Compared with RFT alone, RFT combined with CS does not seem to show better efficacy but increases the occurrence of CH and thoracic neuralgia.

PMID:42874704 | DOI:10.1016/j.jvir.2026.109135

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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