Category: Facial

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Thoracoscopic Sympathectomy for Primary Hyperhidrosis: A 3 mm Two-Port Approach

J Laparoendosc Adv Surg Tech A. 2025 Dec 12. doi: 10.1177/10926429251405812. Online ahead of print.

ABSTRACT

Background: Primary hyperhidrosis is a debilitating condition characterized by excessive focal sweating, most commonly affecting the axillae, palms, and soles, for which surgical intervention provides a durable solution in patients refractory to medical management. Methods: We present our outpatient surgical technique for video-assisted thoracoscopic sympathectomy (VATS) using a two-port, 3-mm incision approach and evaluate its efficacy and outcomes. A case series of 33 consecutive patients undergoing outpatient VATS sympathectomy between 2016 and 2023 was reviewed, with 9 patients excluded for lack of postoperative follow-up. All procedures were performed with electrocautery at the third and fourth ribs posteriorly (T3 and T4). Results: The technique demonstrated consistent efficacy in symptom resolution with short operative times, low postoperative pain, and rapid recovery. Mean operative time was 22.0 ± 3.7 minutes, with same-day discharge achieved in all patients. The average pain score at discharge was 2.0 ± 2.6, and no intraoperative or immediate postoperative complications occurred. Symptom severity scores improved across all regions, most notably in the palms (8.8 ± 2.1 to 1.3 ± 2.1, P < .001) and axillae (7.1 ± 2.9 to 2.2 ± 2.3, P < .001), with improvement also observed in plantar sweating (8.6 ± 2.0 to 4.8 ± 3.0, P < .001), while facial sweating showed a modest, nonsignificant change (2.3 ± 2.8 to 1.5 ± 2.2, P = .21). At 2-4 weeks, complication rates, including compensatory hyperhidrosis and pneumothorax, were comparable to conventional methods. Conclusion: This minimally invasive two-port VATS sympathectomy with 3-mm incisions appears safe, effective, and patient-centered, supporting its use as a surgical approach for primary hyperhidrosis.

PMID:41467293 | DOI:10.1177/10926429251405812

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Beyond the Axilla: The Evolving Role of Botulinum Toxin in the Treatment of Facial, Scalp, and Focal Hyperhidrosis

Clin Dermatol. 2025 Dec 27:S0738-081X(25)00336-0. doi: 10.1016/j.clindermatol.2025.12.003. Online ahead of print.

ABSTRACT

Botulinum toxin type A (BoNTA) is an established treatment for focal hyperhidrosis of the axillae and palms, but its use has recently expanded to include craniofacial, facial, and scalp hyperhidrosis. This systematic review with narrative synthesis evaluates the clinical use of BoNTA for focal hyperhidrosis across multiple anatomical sites. A structured search of PubMed/MEDLINE, Embase, and Scopus was conducted for English-language human studies published between 2000 and 2025. Original clinical studies reporting outcomes related to sweat reduction, disease severity, quality of life, duration of effect, or adverse events were included, while reviews and non-original publications were used only for background and citation tracking. A total of 33 original clinical studies met inclusion criteria. Evidence was strongest for axillary hyperhidrosis, where randomized controlled trials consistently demonstrated substantial reductions in sweating and sustained patient-reported benefit. Palmar hyperhidrosis showed reliable efficacy, although treatment was limited by injection discomfort and transient weakness. Evidence for craniofacial, facial, and scalp hyperhidrosis consisted primarily of small cohorts and case series, which nevertheless reported meaningful symptom improvement and acceptable safety profiles despite heterogeneity in dosing and injection techniques. Overall, BoNTA remains a cornerstone therapy for focal hyperhidrosis, and while evidence beyond the axillae is less robust, available data support its use in selected patients and underscore the need for larger, standardized studies in craniofacial and scalp hyperhidrosis.

PMID:41461243 | DOI:10.1016/j.clindermatol.2025.12.003

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CT-guided Percutaneous Ethanol Sympatholysis for Hyperhidrosis: How I Do It

Radiology. 2025 Mar;314(3):e241430. doi: 10.1148/radiol.241430.

ABSTRACT

Hyperhidrosis, excessive sweating from the eccrine sweat glands, is caused by overactivity of the sympathetic nerves. Facial, axillary, and/or palmar hyperhidrosis (excessive sweating of the face, armpits, and hands) has a reported prevalence of 1%-1.6%. This condition is initially treated conservatively using a combination of topical and pharmacologic treatments. Surgical sympathectomy or percutaneous sympatholysis are treatment options for severe hyperhidrosis (grade 3 or 4) that does not respond to conservative management. The aim of intervention is to permanently disrupt the sympathetic signal by targeting the thoracic vertebral levels T2, T3, and T4 of the paravertebral ganglia, located on the anterolateral surface of the vertebral body. This review presents the step-by-step technique for CT-guided percutaneous ethanol sympatholysis and discusses patient selection for the procedure, potential complications, and treatment outcomes. Although more than 90% of patients report complete resolution of hyperhidrosis immediately after sympatholysis, as many as 40% report symptom recurrence within 6 months. The probability of remaining hyperhidrosis-free long term (ie, more than 6 months) after CT-guided sympatholysis is 60%. Procedural risks include a 15% risk of compensatory hyperhidrosis elsewhere in the body, 8% risk of Horner syndrome (mostly self-limiting), 5% risk of pneumothorax, and 3% risk of severe intercostal neuralgia due to nontarget ethanol deposition. Despite the risks, this intervention can be life-altering for those with severe disease.

PMID:40100019 | DOI:10.1148/radiol.241430

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Changes in electrodermal activity following sympathicotomy in hyperhidrosis patients

Front Surg. 2024 Mar 11;11:1358357. doi: 10.3389/fsurg.2024.1358357. eCollection 2024.

ABSTRACT

OBJECTIVES: The aim of this study was to assess the potential of electrodermal activity (EDA) as a diagnostic tool for preoperative evaluation in hyperhidrosis patients. EDA levels and patterns in different skin areas were investigated before and after endoscopic thoracic sympathicotomy (ETS) and was compared to healthy subjects.

METHODS: Thirty-seven patients underwent two days of measurements before and after the operation. Twenty-five (67.5%) of the patients also had a third measurement after six months. Non-invasive EDA measurements, involving skin conductance, were sampled from five different skin areas while patients were at rest in supine and sitting positions or when subjected to stimuli such as deep inspirations, mental challenge, and exposure to a sudden loud sound.

RESULTS: Prior to the operation, hyperhidrosis patients showed higher spontaneous palm EDA variations at rest and stronger responses to stimuli compared to healthy subjects. Patients with facial blushing/hyperhidrosis or combined facial/palmar hyperhidrosis showed minimal spontaneous activity or responses, particularly during mental challenge and sound stimulus. Notably, palm EDA response was abolished shortly following sympathicotomy, although a minor response was observed after six months. Minimal EDA responses were also observed in the back and abdomen postoperatively.

CONCLUSION: Hyperhidrosis patients showed stronger EDA response to stimuli compared to healthy subjects. Sympathicotomy resulted in the complete elimination of palm EDA responses, gradually returning to a limited extent after six months. These findings suggest that EDA recordings could be utilized in preoperative assessment of hyperhidrosis patients.

PMID:38529470 | PMC:PMC10961364 | DOI:10.3389/fsurg.2024.1358357

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Evaluation of quality of life (QOL) of young patients with primary hyperhidrosis (PH) before and after endoscopic thoracic sympathectomy (ETS)

J Am Acad Dermatol. 2023 May;88(5):e197-e201. doi: 10.1016/j.jaad.2015.10.048.

ABSTRACT

BACKGROUND: Primary hyperhidrosis (PH) affects young patients and may cause emotional distress and a negative quality of life (QOL).

OBJECTIVE: We sought to evaluate the QOL of children and adolescents with PH treated by endoscopic thoracic sympathectomy.

METHODS: A study of 220 patients was performed, based on submitted QOL questionnaires from their first consultation. Patients were evaluated within 1 week and 24 months after surgery.

RESULTS: Before endoscopic thoracic sympathectomy, the QOL in relation to PH was declared very poor by 141 patients, and poor by the remaining 79 (P = .552). Postoperative cure was reported in 100% of palmar and axillary PH cases, and in 91.7% of facial PH. After 24 months, the QOL was described as much better by 212 patients, a little better by 6 patients, and 2 patients reported no change.

LIMITATIONS: Convenience sampling was used and patients were taken from private practice only, raising the possibility of bias in gathering the data.

CONCLUSION: Onset of PH symptoms was mainly before the age of 10 years and substantially affected daily activities. Endoscopic thoracic sympathectomy cured PH and promoted significant improvement in the QOL of these young patients.

PMID:37069802 | DOI:10.1016/j.jaad.2015.10.048

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Microneedling Delivery of Botulinum Toxin Versus Intradermal Injection in the Treatment of Facial Hyperhidrosis

J Clin Aesthet Dermatol. 2022 Sep;15(9):40-44.

ABSTRACT

BACKGROUND: The current treatments of Facial hyperhidrosis (FH) are often limited and are associated with many adverse effects.

OBJECTIVE: The objective was to study the efficacy and safety of botulinum toxin-A delivery by microneedling versus its intradermal injection in the treatment of FH. Forty-two patients with FH were subjected to microneedling (Mn) followed by topical application of BTX-A on one side of the face and intra-dermal injection of BTX-A on the other side. Two sessions were performed at two week intervals. The assessment tools were Hyperhidrosis Disease Severity Scale (HDSS), the Dermatology Life Quality Index (DLQI), and patient satisfaction.

RESULTS: A score of one of HDSS was achieved in 85.7 percent of patients on the intradermally injected side versus 83.3 percent on the microneedling side (P=0.76%). Most of the patients on the injection side responded with the first session while the microneedling side responded with the second one (P<0.001). The DLQI was highly significant on both sides post-treatment (P<0.001). The side effects were mild in the form of pain on the intradermally injected sides, and mild transient erythema on the microneedling side. The microneedling side showed higher patient satisfaction compared to the intradermally injected side.

CONCLUSION: Both techniques were safe and effective in controlling the FH. Microneedling delivery of BTX-A was less painful and had higher patient satisfaction.

PMID:36213604 | PMC:PMC9529074

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Intradermal Botulinum Toxin A Injection Versus Topical 2% Glycopyrrolate for the Treatment of Primary Facial Hyperhidrosis: A Pilot Study and Review of Literature

Dermatol Surg. 2022 Aug 1;48(8):843-848. doi: 10.1097/DSS.0000000000003490. Epub 2022 Jun 17.

ABSTRACT

BACKGROUND: Facial hyperhidrosis (HH), a common problem with both cosmetic and psychological impact, interferes with quality of life. Wide range of treatment options is available for HH. Finding the most effective and yet a safe, tolerable option is the main target.

OBJECTIVE: To evaluate and compare clinical efficacy, safety, and tolerability of topical 2% glycopyrrolate versus intradermal Botulinum toxin A injection in facial HH treatment.

MATERIALS AND METHODS: Twenty-four patients with primary facial HH were randomly divided into 2 equal groups: Group A included patients treated by intradermal Botulinum toxin A injection and Group B included patients treated by topical glycopyrrolate gel 2%. Starch iodine test was performed before and after treatment to assess response, along with Hyperhidrosis Disease Severity Scale, Dermatology Life Quality Index (DLQI), and patient satisfaction.

RESULTS: Both modalities showed complete response in 75% of cases with a longer duration of action in botulinum toxin group up to 6 months. Side effects were minor and temporary. Both Hyperhidrosis Disease Severity Scale and DLQI showed statistically significant improvement after treatment.

CONCLUSION: Topical glycopyrrolate 2% showed comparable results to Botulinum toxin A in facial HH treatment with faster onset but shorter duration of action.

PMID:35917265 | DOI:10.1097/DSS.0000000000003490

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The Impact of COVID-19 on Hyperhidrosis Patients in the Mental Health and Quality of Life: A Web-Based Surveillance Study

J Clin Med. 2022 Jun 21;11(13):3576. doi: 10.3390/jcm11133576.

ABSTRACT

BACKGROUND: We aimed to investigate the impact of the COVID-19 pandemic on the degree of depression among hyperhidrosis patients and their quality of life.

METHODS: 222 patients were contacted through an online questionnaire. Patients reported quality of life (QoL), including treatment and changes in symptoms during the pandemic, and also responded to the Patient Health Questionnaire-9 (PHQ-9) to evaluate the severity of depression. Those were compared with the result from the general population. Spearman correlation and multiple linear regression were performed to identify the factors related to the PHQ-9 score.

RESULTS: Half of the patients were female. The mean PHQ-9 score (5.25) of hyperhidrosis patients was higher than the general population, and female patients displayed significantly higher PHQ-9 scores than males (p = 0.002). QoL was impaired more in females. About 10% of patients experienced worsening symptoms, and 30% had difficulties getting appropriate management. Significant negative correlations were found between the PHQ-9 and age or disease duration. Predictive factors for the PHQ-9 were female (p = 0.006) and facial hyperhidrosis (p = 0.024).

CONCLUSIONS: The level of depression among hyperhidrosis patients was higher than the general population during the COVID-19 pandemic; female and facial hyperhidrosis patients need much more psychiatric attention. Though hyperhidrosis is classified as benign and often neglected by clinicians, we need to give more awareness to the mental burden imposed by the COVID-19 pandemic.

PMID:35806865 | DOI:10.3390/jcm11133576