The Treatment of Primary Focal Hyperhidrosis

Todd Wechter, BSc; Steven R. Feldman, MD, PhD; Sarah L. Taylor, MD, MPH


Skin Therapy Letter. 2019;24(1) 

In This Article

Surgical Management

Local Surgical Options

Local surgical management is generally considered one of the last-line options for axillary hyperhidrosis.[8] The principle behind local surgical techniques is to remove the sweat glands, thus theoretically permanently eliminating the source of the disease.[49] Local surgical options typically include destruction and removal of the glands through curettage, suction, excision or a combination of these techniques (Figure 1D).[49–53]

A recent 2017 study of 20 patients with axillary disease found an approximately 80% mean reduction in sweat rate 3 months after treatment with suction curettage.[50] Interestingly, there was no significant difference in mean sweat rate reduction between suction-curettage and BTX-A treated groups (mean sweat rate reduction of 68.22 mg/min vs. 71.17 mg/min, respectively, p=0.21).[50] This finding was corroborated in another study that demonstrated similar efficacy between the two treatment options, with a mean sweat rate reduction of 60.4% and 72.1%, for suction curettage and BTX-A injection treated groups, respectively (p=0.29).[51]

Suction curettage has persistent results.[52] In a prospective study of 28 patients treated with axillary suction curettage, the mean resting sweat rate of treated patients was reduced by 58% from baseline at 1 year follow-up.[52] The study also noted that suction curettage was more effective in patients with higher baseline sweat rates, which led the authors to question the use of the procedure in patients with pre-operative sweat rates of less than 25 mg/min.[52]

Axillary skin excision is a less commonly used treatment method for hyperhidrosis, and there are multiple techniques available with varying amounts of tissue excision.[49,53] In a 2006 prospective study of patients with axillary hyperhidrosis, treatment with local skin excision resulted in a mean sweat reduction of 65% as assessed by post-operative patient reporting.[49] Another 56 patient retrospective study found that 88% of patients undergoing axillary skin resection were satisfied with the results 3 months after surgery.[53]

Although surgical methods carry more significant adverse effects than less invasive treatment options, they remain an alternative for patients with refractory axillary disease.[49–53] Major side effects of local surgical options include pain, bruising, bleeding, swelling, scaring, and infection.[49–53]


Sympathectomy is the most invasive surgical procedure for primary focal hyperhidrosis and is reserved as a last-line treatment option for refractory palmar, axillary and craniofacial disease.[8] By surgically damaging the thoracic sympathetic outlets, the upstream source of eccrine gland stimulation is disrupted, leading to symptomatic relief (Figure 1A).[54] The surgery is often done endoscopically and there are multiple methods of sympathetic interruption, including cutting, clipping and electrocauterization.[54–57] Although effective, a major limitation of sympathectomy is compensatory sweating.[54,55,57]

One study of 283 patients that had undergone bilateral T3-T4 endoscopic sympathectomy demonstrated a mean sweat rate reduction of 91.8% and 63.3%, in the palms and axilla, respectively.[55] These results were persistent through 3 years of follow-up.[55] Although most patients experienced compensatory sweating, approximately 76% considered it acceptable at 3 years follow-up.[55]

In a study of 352 patients undergoing thoracoscopic sympathectomy, 91.1% reported dry skin after an average of 16 years of follow-up.[57] The surgery was more effective for palmar disease than axillary disease, and high rates of compensatory sweating were again noted.[57]

Additional research has examined less invasive surgical methods of disrupting sympathetic outflow.[56,58–60] For example, singleport videoscopic surgery is a safe and effective method of minimally invasive sympathectomy.[56,60] Smaller incisions with a needlescopic approach have also been successfully attempted.[58,59]

Surgical sympathectomy is an invasive procedure and carries typical surgical risks.[54] Major side effects include pneumothorax, Horner's syndrome, neuropathy, subcutaneous emphysema and bradycardia.[54,55,57]