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Palmar Hyperhidrosis

Cardio-thoracic Surgery

Palmar Hyperhidrosis is caused by an abnormality of the sympathetic nervous system that regulates sweat secretion, leading to sweating of the palms even when it is not needed. When severe, this condition can interfere with daily tasks and social activities. Video-assisted thoracoscopic surgery (VATS) can rapidly relieve symptoms by removing the affected sympathetic nerves.

Symptoms

Constantly moist palms: Persistent sweating regardless of ambient temperature or activity level.
Difficulty gripping: Items slip from wet hands, impairing fine motor tasks.
Social anxiety: Embarrassment and avoidance of handshakes or public activities, potentially lowering self-esteem.

Causes

Neural over-stimulation: Excessive firing of thoracic sympathetic fibers (T2–T3) that innervate palmar sweat glands.
Genetic predisposition: Family history is found in 30–50% of cases.
Emotional triggers: Stress, anxiety, or excitement can exacerbate sweating episodes.

Risk Factors

Family history of hyperhidrosis in first-degree relatives.
Onset during adolescence: Symptoms often begin in teenage years.
High stress levels: Chronic emotional stress may worsen the condition.

Diagnosis

Clinical assessment	Detailed history of sweating patterns and severity, often scored with the Hyperhidrosis Disease Severity Scale (HDSS).
Sweat testing	Minor’s starch-iodine test: Iodine and starch applied to palms turn dark in areas of active sweating. Gravimetric measurement: Collection and weighing of sweat over a defined period for quantitative evaluation.
Rule out secondary causes	Laboratory tests to exclude hyperthyroidism, infection, medication side effects or other systemic disorders.

Treatments

Conservative Therapies

Topical antiperspirants: Aluminium chloride hexahydrate solutions (20–25%), effective but may irritate skin.
Iontophoresis: Electric current applied through water bath to reduce gland activity; requires regular maintenance sessions.
Oral anticholinergics: Medications such as oxybutynin can reduce sweating systemically but may cause dry mouth, blurred vision or urinary retention.
Botulinum toxin injections: Blocks sympathetic nerve terminals locally; effects last 6–9 months, requiring repeat treatments.

Endoscopic Thoracic Sympathectomy (ETS)

Indications: HDSS score of 3–4 and failure of conservative measures.

Procedure: Under general anaesthesia, bilateral VATS incisions allow identification and ablation or resection of a short segment of sympathetic chain.
Efficacy: Success rates of 80–100%, with immediate cessation of palmar sweating. Operative time averages 40–90 minutes; typical hospital stay is 1–2 days.
Complications: Low risk of Horner’s syndrome; compensatory sweating.

FAQ

Compensatory sweating after ETS cannot be totally prevented. Patients are advised to discuss thoroughly with doctors about the pros and cons of the surgery. Severe cases can be treated with localised botulinum toxin injections.

Removal of superficial sympathetic fibers has minimal impact on cardiopulmonary function. Rarely patients may have slower heart rates after ETS.

Patients may ambulate on the day of surgery, be discharged on postoperative day 1–2, resume light activities by 1 week, and full activities by 4 weeks.

Most patients achieve bone-dry palms immediately. A small number may experience minimal residual sweating or recurrence.