Management of Hyperhidrosis

The recent Thoracic Portal survey addressed surgical management of hyperhidrosis. Respondents were asked to answer questions related to a 23 year old woman with severe palmar and mild plantar hyperhidrosis that importantly affected her work and social lives.

Relatively equal numbers of respondents would recommend surgical therapy either as an initial treatment or after failure of a single conservative treatment modality. About half of respondents would indicate a likely success rate for palmar hyperhidrosis >95%, and most of the rest of the respondents would indicate a success rate >90%.

The outcomes for plantar hyperhidrosis were more mixed. Equal numbers of respondents stated that the likelihood of success was >50% or wouldn?t quote numbers in the discussion. The remaining respondents would indicate the likelihood of success was >75% or was ?high.?

The greatest amount of disagreement involved the appropriate levels for sympathectomy/sympathotomy. Only a few surgeons would operate only at the T2 level, whereas relatively similar numbers of surgeons would recommend operating at levels T2/T3, T3 only, T3/T4, or T2-T4. This indicates the need for better data regarding outcomes of treatment for this problem.

Similar numbers of surgeons cut the nerves without removing a segment or cut and remove a segment of the nerves. Fewer than 15% of respondents use clipping as the primary technique for treating hyperhidrosis. The majority of surgeons admit patients for an overnight hospital stay, whereas a quarter of surgeons perform the operation on an outpatient basis.

1. What do you require prior to recommending surgery to this patient?
	answered question		176
	skipped question		1
		Response Percent	Response Count
Failure of at least one conservative therapy such as topical 20% aluminum chloride, iontophoresis, or botulinum toxin injection.		37.5%	66
Failure of at least two conservative therapies.		19.3%	34
Surgery is the best initial therapy and I would recommend it without concern for any prior treatment.		43.2%	76

2. What would you tell the patient about expectations for improvement in her palmar hyperhidrosis?
	answered question		174
	skipped question		3
		Response Percent	Response Count
>95% success		48.9%	85
>90% success		40.8%	71
Guaranteed success		2.9%	5
I don?t quote numbers in such discussions		7.5%	13

3. What would you tell the patient about expectations for improvement in her plantar hyperhidrosis?
	answered question		172
	skipped question		5
		Response Percent	Response Count
>50% success		35.5%	61
>75% success		12.2%	21
A high rate of success		16.9%	29
I don?t quote numbers in such discussions		35.5%	61

4. What levels do you recommend treating for this patient?s pattern of excessive sweating?
	answered question		175
	skipped question		2
		Response Percent	Response Count
T2 only		5.7%	10
T2 and T3		31.4%	55
T3 only		20.0%	35
T3 and T4		24.0%	42
T2-T4		18.9%	33

5. Which technique do you use for managing the nerves intraoperatively?
	answered question		172
	skipped question		5
		Response Percent	Response Count
Cutting and removing a segment of nerve		47.1%	81
Cutting without removing a segment of nerve		39.5%	68
Clipping		13.4%	23

6. What is the duration of postoperative hospitalization for these patients?
	answered question		175
	skipped question		2
		Response Percent	Response Count
I perform this on an outpatient basis		27.4%	48
1 night stay		64.6%	113
2 night stay		8.0%	14
>2 night stay		0.0%	0

7. In what region do you work?
	answered question		169
	skipped question		8
		Response Percent	Response Count
North America		39.6%	67
Europe		29.0%	49
South America		15.4%	26
Asia		11.8%	20
Africa		4.1%	7
Other (please specify)			11