Blushing Research Articles

Sympathetic ganglionectomy for facial blushing using application of laser speckle flow graph

ObjectiveEndoscopic thoracic sympathectomy at the second rib level is considered effective as a therapeutic treatment for facial blushing. However, 10% to 15% of patients do not benefit from this intervention. No additional procedure has been developed for this disorder. Recently, ganglionectomy using application of laser speckle flow graph has been evaluated for the treatment of compensatory sweating. We report our results of ganglionectomy for facial blushing as a redo surgery. MethodsBetween August 2012 and April 2017, 8 patients with facial blushing who underwent an initial sympathectomy reported symptom recurrence. Seven patients had undergone transection of the sympathetic trunk at the second rib and 1 patient had undergone transection of the sympathetic trunk at the second and third ribs. These patients were treated using ganglionectomy guided by application of laser speckle flow graph. After temporary decreases in facial skin blood perfusion were confirmed by stimulating the sympathetic ganglions, ganglionectomy was performed. ResultsAll patients' symptoms improved. There were no side effects, including deterioration of compensatory sweating, worsening of gustatory sweating, or Horner syndrome. There were no cases of mortality or conversion to open surgery. ConclusionsThis study shows the effectiveness of ganglionectomy for the treatment of facial blushing, representing a new treatment option for this condition. Considering the mechanism of facial blushing, it is important to recognize that ganglionectomy is effective after the interception of the sympathetic trunk on the cranial side.

The efficacy of oral anticholinergics for sympathetic overactivity in a thoracic surgery clinic

ObjectiveLittle is known of the success rates of oral anticholinergics for the treatment of primary hyperhidrosis and facial blushing as alternatives to surgical intervention. We examine predictors of success with these medications. MethodsA retrospective review was performed at a single institution, including all patients presenting with symptoms of primary hyperhidrosis, facial blushing, or both from 2004 to 2015. All patients were offered a trial of oral anticholinergics. If oral anticholinergic therapy was not successful, patients were offered surgery. Statistical analyses were performed to compare patients who declined surgery given the trial of oral anticholinergics with those who proceeded with surgery. ResultsA total of 381 patients presented with symptoms of primary hyperhidrosis (86.6%), facial blushing (2.4%), or both (11.0%). A total of 230 patients (60.4%) declined surgery after using oral anticholinergics, and 151 patients (39.6%) chose surgery. Patients who declined surgery were more likely to have symptoms of primary hyperhidrosis without facial blushing (89.6% vs 82.1%; P = .02) or have primary symptoms involving the axilla, torso, scalp, or groin. Patients who proceeded with surgery had higher rates of palmar symptoms as a primary site (77.6% vs 61.1%; P = .01) and were more likely to have facial blushing alone or in combination with primary hyperhidrosis. Presentation with palmar symptoms and greater number of prior therapy attempts were independent predictors of proceeding with surgery after controlling for concomitant symptom type and location (P = .01 and P < .0001, respectively). ConclusionsThe majority of patients presenting with sympathetic overactivity decline surgery when a trial of oral anticholinergics is included in the treatment algorithm. Facial blushing and palmar symptoms were each associated with choosing surgery.

Plantar Sweating as an Indicator of Lower Risk of Compensatory Sweating after Thoracic Sympathectomy.

Background Hyperhidrosis is a dysfunction of the autonomic nervous system that results in regional excessive sweating, mostly in the hands, armpits, and feet. A permanent and effective treatment of hyperhidrosis can be achieved by interruption of the thoracic sympathetic chain with endoscopic thoracic sympathectomy (ETS). However, some side effects, particularly compensatory sweating (CS), are the limitations of this procedure. The mechanism of CS and the associated risk factors are still controversial. The aim of this retrospective study was to determine the relationship with various parameters associated with CS in patients undergoing ETS. Materials and Methods ETS was performed on a total of 95 patients for palmar hyperhidrosis, axillary hyperhidrosis and facial blushing by the same surgeon. The mean age of the patients was 26.41 (± 7) years, and 54 (56.8%) were males. Palmar hyperhidrosis was present in 54 (56.8%) patients, axillary hyperhidrosis in 33 (34.7%) patients, and facial blushing in 8 (8.5%) patients. Moreover, 38 (40%) patients also had plantar sweating. The severity of CS was rated into three scales as less, moderate, and severe. Results Regarding the severity of CS, 55 (57.9%) patients had no or less CS, 28 (29.5%) had moderate CS, and 12 (12.6%) patients had severe CS. Higher age group had a significant increased risk of severe CS (p = 0.03) (r = 0.262). Patients with body mass index (BMI) > 25 kg/m2 had a statistically significantly increased risk of severe CS (p = 0.016). Facial blushing resulted in severe CS in a significantly higher proportion of patients than by palmar and axillary hyperhidrosis (p = 0.001). The level of surgery was another important risk factor for CS, with the T2 level showing an increased risk of severe CS compared with T3 level (p < 0.001). Furthermore, plantar sweating was inversely and significantly related to the development of CS. Patients with plantar sweating had a significantly decreased incidence of developing CS (p = 0.015). Conclusion CS after thoracic sympathectomy for primary hyperhidrosis is the most displeasing and restrictive side effect. This study demonstrates that older age, operation level, facial blushing, and high BMI are risk factors for CS, as have been shown in several similar studies. An interesting finding of the present study is that there was a decreased incidence of CS among patients with plantar sweating. This situation may help us to distinguish high risk for CS before ETS operation.

The relationship between social anxiety, shyness and blushing

The diagnosis of social anxiety disorder (SAD) has seen substantial changes in the last 35 years from its first appearance in the DSM-III in 1980 up to the most recent ones in the DSM-5. Throughout all these changes, this disorder, previously called social phobia, is still considered one homogenous entity with only one specifier (“performance only”) introduced in the DSM-5 revision with specific fears or associated personality profiles not being considered relevant clinical markers to define SAD subtypes. However, our therapeutic experience suggested substantial particularities associated with the fear of blushing in patients with SAD. Some patients presenting this profile, historically called “erythrophobia”, seem to have a very specific type of social anxiety that does not include shyness and other characteristics of classical SAD. In a study conducted in a sample of 450 new consecutive outpatients seeking treatment for SAD, we compared 142 subjects with fear of blushing without other social fears, 97 subjects with fear of blushing with other associated social fears and 190 SAD subjects without fear of blushing. The group with pure fear of blushing presented a different profile when compared with the two other groups: later age of onset, less comorbidity, lower behavioral and temperamental inhibition, i.e. less shyness, and higher self-esteem. Furthermore, from a therapeutic point of view, some specific strategies such as the Task Concentration Training have shown to be particularly effective in fear of blushing. We will further argue the validity of a possible “fear of blushing” subtype of SAD.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cognitive Therapy and Task Concentration Training Applied as Intensified Group Therapies for Social Anxiety Disorder with Fear of Blushing-A Randomized Controlled Trial.

The current study examines the efficacy of intensified group therapy for social anxiety disorder with fear of blushing. Task concentration training (TCT) and cognitive therapy (CT) were applied during one weekend and compared with a waiting list condition in a randomized controlled trial including 82 patients. On a second weekend, another intervention was added (resulting in TCT-CT and CT-TCT sequences) to examine order effects. Task concentration training and CT were both superior to the waiting list and equally effective after the first therapy weekend. Also, no differences were found between the sequences TCT-CT and CT-TCT at post-assessment. At 6- and 12-month follow-up, effects remained stable or further improved. At the 6-month follow-up, remission rates in completers, established by diagnostic status, were between 69% and 73%. Intensified group therapy is highly effective in treating social anxiety disorder with fear of blushing. Group formats for patients sharing a common primary concern may contribute to the dissemination of cognitive-behavioural therapy. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Message: This study focuses on blushing from fearful individuals within the SAD spectrum to improve evidence for treatment efficacy in those whose social fears are centred around observable bodily sensations. This study integrates task concentration training into the SAD model of Clark and Wells to combine two evidence-based treatments for SAD under one treatment model. This study uses an innovative format of brief, intensified group therapy, conducted on two full-day weekend group sessions delivered over two weekends, with strong observed effect sizes.

Thoracic sympathectomy: a review of current indications.

Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice. The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required. Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Judgmental Biases of Individuals with a Fear of Blushing: The Role of Relatively Strict Social Norms.

Blushing-fearful individuals attribute relatively strict social norms to other people about which behaviours are appropriate and which are not and have stricter personal norms as well. Blushing-fearful individuals' tendency to expect overly negative judgments in ambivalent social situations can partly be explained by their relatively strict social norms. Having relatively strict social norms may (also) explain why blushing-fearful individuals report to blush often and intensely. It may be worthwhile to address strict social norms in therapy for fear of blushing.

Invited Commentary

Invited Commentary

Intrapersonal and interpersonal concomitants of facial blushing during everyday social encounters.

Facial blushing may usually be undesirable but may have an ameliorative function for some individuals under some circumstances. Researchers have studied the blush in laboratory settings, but not in daily life. In the present research, conducted with young adults, we employed for the first time an event-contingent recording method for assessing facial blushing during every-day social encounters. Blushing was associated with feeling embarrassed, ashamed, and exposed. These findings, though based on correlational analyses, are consistent with the idea that blushing is often unpleasant and can be maladaptive, and may contribute to the common belief that blushing is an undesirable response. Frequent blushers generally reported lower levels of dominant behavior, higher levels of submissive behavior, and perceived their social interaction partners as more powerful and less affiliative. This was independent of whether they blushed or not, suggesting that altered social behaviors and perceptions are associated with blushing-associated traits rather than with the blushing state. The experience of the blush varied as a function of the frequency with which a person blushed. Blushing was associated with higher levels of shame in frequent blushers than in infrequent blushers. In infrequent blushers, blushing was associated with higher levels of pleasant affect, suggesting that for infrequent blushers the blush may occur in positive social encounters.

Reversal of Sympathetic Interruption by Removal of Clips

Sympathetic interruption offers excellent control of hyperhidrosis and facial blushing (FB), but some patients have side effects prompting a wish to reverse the procedure. Reversal when the chain has been cut is challenging, whereas reversal when the chain has been clipped is straightforward. The peripheral nerves regenerate; however, little is known about the regeneration of the sympathetic chain after clip removal. We reviewed our results with reversal of sympathetic interruption through removal of clips. An institutional review board-approved retrospective review of patients treated for hyperhidrosis and FB from November 2004 to March 2014 was performed. We analyzed those patients undergoing sympathetic interruption with clips (N= 82). Eight patients (10%) requested and underwent reversal of the procedure between 12 days and 5.8 years (median= 73.5 days) after the initial procedure. Compensatory sweating was the most frequent complaint (n= 6), and excessive palmar dryness was second (n=3), the latter occurring in patients without primary palmar hyperhidrosis. The interval between clip removal and follow-up ranged from 2 days to 4.5 years (median= 141 days). Five of 8 patients thus far have had their symptoms reversed through removal of clips (Table1). The percentage of patients requesting reversal of sympathectomy is significant and appears to most commonly result from compensatory sweating (CS); however, excessive palmar dryness also occurs in those without primary palmar hyperhidrosis. It appears that the best results with reversal are obtained when the clips are removed early after placement. We counsel our patients that ideally clips should be removed within 2 weeks for reversal.

Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation.

The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing. We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods. Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period. Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts.

Sympathetic block by metal clips may be a reversible operation.

Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4-6 weeks after clip removal, but they only used conventional histopathological staining methods. Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls. Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized. Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip.

Fear of blushing: Relations with personality among children and adults

Despite the common nature of blushing and the feelings of discomfort that often accompany it, to date, no studies have yet examined the relationship between personality characteristics and the fear of blushing. The present study fills this gap in the literature, by examining, in a sample of adults and a sample of children (9–16years), the relationship between personality and fear of blushing. For this purpose questionnaires were administered to representative community samples of adults (n=157) and children (n=150). Results showed that, among adults, fear of blushing was best predicted by Structure, whereas, among children, fear of blushing was best predicted by Neuroticism. When comparing the two samples, children reported more fear of blushing than adults, whereas, across samples, females reported more fear of blushing than males. Conclusions are discussed as well as future directions for research.

Seeing through the Fog of Myth

Benjamin’s early aesthetics reconsiders the meaning of line and colour by observation of their relationships to the signs of guilt and the scrawls of ‘innocent’ children. Transparent colours found in illustrated children’s books and the transiency of facial blushing caused Benjamin to hypothesise about certain redemptive effects of invisible rays on the turbid appearance of sin-stained or disgraced creatures. He further developed these ideas by his critical reading of Simmel’s philosophy. Simmel used analogies of colour and blood circulation to characterise law and economy as special ‘forms’ of life which transcend life itself and impose their quantitative evaluations (fine, reward etc.) on individuals. In Benjamin’s view, those who become familiar with the notion of Schuld (guilt/debt) become obedient to those forms in the ‘fog’ of mythic fate. The ‘flâneur’ exemplified such obedience in the lap of the arcades. He was dependent, like an embryo, on the fertility of our debt-producing economy. Benjamin tried to expose flâneurs to awakening illumination by staging the arcades (together with his own bourgeois childhood) in a changing light. He forces us to read their reactions to the threatening forces in the colour of their faces.

The medieval origins of the concept of hypertension.

Despite the well-known history of hypertension research in the modern era, like many other cardiovascular concepts, main points in the medieval concept of this disease and its early management methods remain obscure. This article attempts to make a brief review on the medieval origin of the concept of this disease from the Hidayat of Al-Akhawayni (?-983 AD). This article has reviewed the chapter of “Fi al-Imtela” (About the Fullness) from the Hidβyat al-Muta’allimin fi al-Tibb (The Students' Handbook of Medicine) of Al-Akhawayni.The definition, symptoms and treatments presented for the Imtela are compared with the current knowledge on hypertension. Akhawayni believed that Imtela could result from the excessive amount of blood within the blood vessels. It can manifest with symptoms including the presence of a pulsus magnus, sleepiness, weakness, dyspnea, facial blushing, engorgement of the vessels, thick urine, vascular rupture, and hemorrhagic stroke. He also suggested some ways to manage al-Imtela'. These include recommendations of changes in lifestyle (staying away from anger and sexual intercourse) and dietary program for patients (avoiding the consumption of wine, meat, and pastries, reducing the volume of food in a meal, maintaining a low-energy diet and the dietary usage of spinach and vinegar). Al-Akhawayni's description of “Imtela,” despite of its numerous differences with current knowledge of hypertension, can be considered as medieval origin of the concept of hypertension.

A single incision transaxillary thoracoscopic sympathectomy

Primary hyperhidrosis causes are unknown. The disorder begins in early childhood. It intensifies in puberty and maturity. It is equally present in both sexes. The symptoms exacerbate when the body temperature rises and due to emotional stimuli affecting the sympathetic nerve system. The aim of this study was to demonstrate that video-assisted thoracoscopic surgery (VATS) sympathectomy is a method for primary focal hyperhidrosis permanent treatment. The single incision method in properly selected patients maximizes the intervention effectiveness and minimizes aesthetic side effects. This prospective study analysed the findings in patients who had been operated on due to primary focal hyperhidrosis (face, palms, and armpits) using a single small transaxilarry incision in the third inter-rib space at the level of the anterior axillary line with two 5 mm flexible ports. All the patients, with T2-T5 thoracoscopic sympathectomy of the sympathetic chain using a single small incision in the third inter-rib space in the anterior axillary line, were analysed in the period from September 2009 to November 2010 regarding the postoperative morbidity and outcomes of the operation (clinical evaluation and visual analogue scale) with a view to assessing the effectiveness of the surgery conducted in this manner. A total of 47 patients (18 men, 29 women), 18 to 48 years old (29 on average) had underwent 94 bilateral video-assisted thoracoscopic sympathectomies. The sympathectomy was indicated in cases of facial blushing and sweating (6.38%), palmary sweating (34.04%), axillary sweating (14.89%) or both palmary and axillary sweating (44.68%). The largest percentage of patients (98.6%) had left the hospital the following day. The postoperative 30 day's mortality was 0 and the conversion into open surgery was not necessary. As for complications, there had been an occurrence of partial pneumothorax in two patients treated by means of exuflation and chest drain, and one case of unilateral transitory Homer's syndrome. Quarterly and annual postoperative monitoring showed excellent aesthetic effects of the surgery without any residual pain. The complete withdrawal of hyperhidrosis symptoms was noted in 44 (93.62%) of the patients. The recurrence of symptoms following the initial regression was seen in 3 (6.38%) of the patients 12 months after the surgery, whereas the patients surgically treated as a result of facial hyperhidrosis saw a significantly increased sweating of feet. The quality of life improved in 45 (95.6%) of the patients. Single incision transaxillary thoracoscopic sympathectomy generates excellent aesthetic and functional results in patients with primary focal hyperhidrosis.

Influence of alcohol on social anxiety: An investigation of attentional, physiological and behavioral effects

Social anxiety disorder and alcohol use disorders are highly comorbid. It remains unclear, however, if and how alcohol influences attentional processes and physical symptoms in social anxiety. In a balanced-placebo-design, high and normally socially anxious participants gave a speech while performing a task, which simultaneously measures internal and external attention. Only high anxious participants showed a preferential processing of external probes, which was eliminated by alcohol or the mere expectation of drinking alcohol. Furthermore, alcohol reduced facial blushing as well as self-reported social anxiety during public speaking. Decreases in anxiety were significantly associated with a reduction of the external focus in the high anxious group. Understanding alcohol as a substance influencing cognitive processes as well as physiological symptoms of anxiety further contributes to our understanding of alcohol use as a safety behavior in social anxiety disorder.

Open-Label Treatment With Escitalopram in Patients With Social Anxiety Disorder and Fear of Blushing

Fear of blushing (FB) is a form of social anxiety disorder (SAD) characterized by an intense and obsessive threat of blushing in front of other people. No data are available on the specific efficacy of antidepressants on FB. This open-label pilot study investigated whether the selective serotonin reuptake inhibitor escitalopram specifically improves symptoms of FB in SAD patients. Thirty-nine patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for SAD and presenting a significant FB according to the Salpêtrière Erythrophobia Questionnaire (SEQ) were administered open-label escitalopram (10-30 mg/d) for 12 weeks. A systematic assessment, at baseline and at week 12, included the SEQ, the Liebowitz Social Anxiety Scale, and the Hospital Anxiety and Depression scale. From the 39 patients included, 31 attended the week 4 visit, and 28 the week 12 visit. Significant reductions of FB were observed after 4 weeks of treatment and were more pronounced at the end of the 12-week treatment since patients experienced a 60% decrease in their FB symptoms (P < 0.001). Nineteen subjects (67.8%) reported a 50% decrease or more of their SEQ score, and 14 (50%) met criteria for remission of FB (SEQ score <7). The effect sizes of changes on SEQ, Liebowitz Social Anxiety Scale, and Hospital Anxiety and Depression scale scores were high, with η² ranging between 0.53 and 0.86. Results of this open-label study suggest that escitalopram can be a useful treatment for FB associated with SAD, even if large controlled trials are now needed to further evaluate this result.

Reply to Garcia Franco et al.

We have discussed the letter to the editor written by Garcia Franco et al. [1], relating to our study [2]. We also reviewed the article by the same authors in 2011, entitled ‘Prospective study of percutaneous radiofrequency sympathicolysis in severe hyperhidrosis and facial blushing: efficacy and safety findings’ [3]. This article is closely related to the aim of our study. Unfortunately, we must confess that we overlooked it while preparing our manuscript: we probably did not come across it whilst searching PubMed for related keywords (sympathectomy, hyperhidrosis, surgery and radiofrequency). We sincerely regret our inability to cite this valuable article. We have been performing the radiofrequency ablation method for treatment of palmar hyperhidrosis since 2007. We prefer to use an approach at the T4 sympathetic ganglion level. Our thoracic surgery department also chooses this level for surgical approach. We have previously presented this technique in several symposia and congresses and believe that it is the best method for treatment of palmar hyperhidrosis. We submitted our assertion, in another article to the journal ’Agri’ in January 2012 and it was published in January 2013 [4]. We believe it is not necessary to compare cost-effectiveness of the surgical operation and interventional treatment. Our approach is, as expected, more cost-effective. There are many other supportive studies about outpatient procedures being cost-effective. We reported all of the surgical complications in our manuscript, however, the minimal complications observed in our study may be related to the experience of the surgical team, which has better outcomes.

Percutaneous radiofrequency sympathicolysis versus surgical standard procedure

We read with interest the recently published paper by Purtuloglu et al. [1]. It retrospectively compared a group of patients treated with surgical sympathectomy with another group who received percutaneous radiofrequency ablation therapy. First, we would like to comment on their final conclusion, particularly on two issues: (i) the amazing statement that they have published ‘the first clinical study to evaluate the role of radiofrequency ablation and compare it with the surgical treatment option for palmar hyperhidrosis’ and (ii) the cost benefit analysis of radiofrequency over surgery that they also mentioned in that section. Concerning the first issue we would like to inform the authors that our group, Garcia Franco et al. [2], published in 2011 the paper ‘Prospective study of percutaneous radiofrequency sympathicolysis in severe hyperhidrosis and facial blushing: efficacy and safety findings’, comparing prospectively both the techniques mentioned. The paper was published in this same Journal. However, we noticed that it has not even been included in the references, even though our paper was probably one of the few in the literature to have compared both procedures. As for the second issue mentioned above, we have not found in their paper any statistics or economic data that supports the statement they make in relation to cost-benefit analysis. Even though it is true that radiofrequency procedures are, in principle, less expensive than surgical ones, a cost-benefit analysis should have included, at least, the ratio of cost between both techniques. Secondly, we would like to indicate the importance of studying, with validated scales, the quality of life, before and after the procedure, to determine the real benefit of these techniques in patients’ lives. In fact, in our series with a decrease of 50% in sweating in the social hand, we proved that quality of life clearly increased. The paper Purtuloglu et al. wrote did not include any quality of life study relating the success of the technique to hand dryness and general satisfaction and this clearly leaves the patient outcome analysis incomplete. Thirdly, we were surprised to read that there were practically no complications with regard to surgical procedures and, in the only complication mentioned in the paper, it is not clear at all what ‘a lung adhesion that did not require surgical treatment’ means. As far as we know, lung adhesions have never been described as surgical complications per se. We actually described in our series several complications after surgical sympathectomy that are normally mentioned in the literature, severe compensatory sweating being particularly relevant and affecting around 5–7% of all patients treated [3]. There is no clear evidence in the literature to establish that compensatory sweating occurs due to the level of sympathectomy performed [4]. For these two reasons, it was interesting to check that no severe compensatory cases were described in the Purtuloglu series, although 46 patients were treated surgically.