Invited Commentary

Abstract

Teivelis and colleagues [1Teivelis M.P. Wolosker N. Krutman M. Milanez de Campos J.R. Kauffman P. Puech-Leão P. Compensatory hyperhidrosis: results of pharmacologic treatment with oxybutynin.Ann Thorac Surg. 2014; 98: 1797-1803Google Scholar] illuminate yet again a well-recognized but poorly understood neurophysiologic side effect of sympathetic operations—that of compensatory hyperhidrosis (CH), occurring predominantly on the truncal regions. The treatment of patients with severe, problematic compensatory sweating is difficult and somewhat limited, but can include anticholinergic agents such as oxybutynin or glycopyrrolate. Most of the 21 patients in the Teivelis and colleagues’ report showed improvement in their CH with oxybutynin treatment, but the anticholinergic side effects became very problematic for some. What needs to be emphasized in no uncertain terms is that the best treatment of CH is prevention by appropriate patient selection and judgment. This appears far more important than the specific ganglion level of the sympathetic intervention per se. Mild hand moisture is not an indication for sympathectomy. The patients happiest with sympathetic operations are those with massive, dripping, debilitating palmar hyperhidrosis, usually exhibiting the classic palmoplantar hyperhidrosis pattern. It is these patients who complain the least about their CH. The complaints of CH are consistently worse for patients with axillary hyperhidrosis or mild palmar hyperhidrosis than for the appropriate, classic cases of typical palmoplantar hyperhidrosis. Is this because of truly quantitatively less compensatory sweating in severe palmar cases, or simply that the resulting CH is so much less disabling than the original palmar hyperhidrosis? The answer is not known. What is known is that it is a rare patient indeed who regrets the cure of his or her massive dripping palmar sweating because of seemingly debilitating truncal CH. Did the patients with severe CH in Teivelis and colleagues’ study really need the sympathetic intervention in the first place? In 6 of the 21 patients, the original sympathetic intervention was done for axillary hyperhidrosis; perhaps these axillary patients (and perhaps all 21 patients) might not have undergone the operation if a rigid selection criteria had been used. Topical aluminum chloride and botulinum toxin works much better for axillary hyperhidrosis than palmar hyperhidrosis, and one or both should be tried before resorting to sympathetic intervention for the axilla. Even local axillary sweat gland resection or liposuction techniques are likely preferable to sympathectomy. Sympathectomy as a first-line treatment is preferred to medical treatment for unmistakably classic dripping palmoplantar cases. But if there is any question, medical treatment should always be used first and surgical intervention only used with trepidation as a last resort. It is telling that none of the patients in the Teivelis and colleagues’ study had ever had prior treatment with oxybutynin. Did they have any medical treatment at all? Interventions have consequences, and mild hand moisture, underarm sweating, stinky feet, or patient desire alone do not warrant surgical sympathectomy as a primary treatment. Compensatory Hyperhidrosis: Results of Pharmacologic Treatment With OxybutyninThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewHyperhidrosis may affect nearly 3% of the population, and thoracic/lumbar sympathectomy has been highly effective. Compensatory hyperhidrosis is a risk associated with surgical procedures, and its treatment is both complex and not well defined. Treatment of primary hyperhidrosis with oxybutynin has yielded positive results; however, its use in compensatory hyperhidrosis (CH) has not been described. Full-Text PDF