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Video-assisted thoracoscopy has replaced all other approaches to the intrathoracic sympathetic ganglionic chain. Thoracoscopic sympathicotomy is the most common treatment of severe palmar hyperhidrosis, although axillary hyperhidrosis, facial sweating, and facial blushing also have been treated with this modality. In addition, thoracoscopic sympathicotomy has been used to treat the rare patient with vasomotor disorder or chronic pain syndrome of the upper extremities.

Hyperhidrosis generally is defined as sweating in excess of physiologic requirements. Although it is possible to quantify the level of increased sweating in comparison with the general population, the diagnosis is established by the characteristic history. Patients typically present between the ages of 18 and 25 years and regularly report palmar and plantar sweating since early childhood. Parents may comment on inordinate wetness of the hands and feet during infancy. Sufferers from hyperhidrosis often relate that grade school classmates would refuse to hold their hands because of excessive wetness and that teachers would berate them for submitting wet, ink-smudged assignments. They describe puddles of sweat accumulating on computer and piano keyboards. As patients enter adulthood, their wet hands begin to adversely affect social interactions and influence career choice, causing many to seek treatment.

Sweating is sporadic and occurs both at times of apparent tranquility and at times of obvious tension. Hyperhidrosis is usually worse during the summer months. While the degree of hyperhidrosis varies, sweating is much greater than the dampness normally associated with stress. A dry hand may become soaking wet within minutes. The volar surfaces of the fingers, thenar and hypothenar eminences, and palmar skin folds fill with perspiration (Fig. 121-1). Sweat frequently drips to the floor.

Figure 121-1.

Typical appearance of palmar hyperhidrosis. Note wetness on thenar and hypothenar eminences as well as on palmar surface of distal phalanges.

Concomitant plantar hyperhidrosis occurs in all patients with palmar hyperhidrosis. Walking barefoot creates footprints similar to those seen after exiting a shower. The constant moistness ruins footwear. However, despite pedal dampness, fungal infections are rare. Concomitant axillary hyperhidrosis with associated garment staining and odor (bromhidrosis) is present in as many as 50% of patients with palmar and plantar hyperhidrosis.1–4

Sufferers from hyperhidrosis avoid direct or indirect hand contact. A handkerchief or tissue is always available. The habitual wiping of hands on clothing is noticeable. In social situations, sufferers often hold a cold drink in their dominant hand to provide an explanation for the need to wipe their hands before a handshake.


The prevalence of palmar and plantar hyperhidrosis is estimated to be between 0.6% and 1%5 and affects all racial groups. Severe axillary hyperhidrosis affects 1.4% of the population of the United States.6 Patients with classic palmar and plantar hyperhidrosis do not have concomitant illnesses, although generalized hyperhidrosis may be associated with thyrotoxicosis, ...

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