Division of Pediatric General, Thoracic and Fetal Surgery

A Guide to Your Child's Surgery

Our Surgery Guide will help you and your family prepare for your child's upcoming surgery, outlining what to expect from the first pre-op visit all the way through to her discharge.

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Hyperhidrosis

What is hyperhidrosis?

Hyperhidrosis is a condition characterized by excessive sweating in amounts greater than what is needed to regulate our body temperature. In most cases, the condition occurs for no apparent reason and is called primary hyperhidrosis. Primary hyperhidrosis usually affects only certain parts of the body, so it is also referred to as primary focal hyperhidrosis. The areas that are most commonly affected by primary focal hyperhidrosis are the palms of the hands, the axillae (armpits), and the feet. Primary focal hyperhidrosis affects 1 to 3 percent of the U.S. population. Males and females are affected equally, and in the majority of patients the condition starts during childhood or adolescence.

Hyperhidrosis can also occur as a result of several medical conditions, including hyperthyroidism and hypertension, in which case it is called secondary hyperhidrosis. Before starting any treatment for hyperhidrosis, all medical conditions that can lead to excessive sweating must be ruled out.

Signs and symptoms

Patients with primary focal hyperhidrosis have constant excessive sweating in the affected areas, regardless of the environmental temperature and the emotional situation. Generally the excessive sweating only stops during sleeping hours and worsens in warm environments and stressful situations. In most patients, more than one area of the body is affected, hands and feet being the most common combination.

Most patients notice the excessive sweating for the first time when the moist palms begin to interfere with school and social activities. Excessive sweating in the hands can severely affect the ability to write, hold papers, use touch-screens, manipulate objects, and perform routine daily activities. It can also cause social embarrassment and impair the patient’s social interactions, which can lead to negative psychological and psychosocial consequences.

Evaluation and diagnosis

After ruling out all potential causes of secondary hyperhidrosis, the diagnosis of primary focal hyperhidrosis is made by physical exam and a detailed evaluation of the patient’s signs and symptoms. No special diagnostic tests or imaging studies are required. The diagnosis is usually made by the patient’s pediatrician or dermatologist.

Treatment approach

Hyperhidrosis can be treated non-surgically or with a surgical procedure.

The Children’s Hospital of Philadelphia offers a wide variety of treatment options for hyperhidrosis. Our expert pediatric dermatologists, led by Dr. Albert C. Yan, offer the full spectrum of non-surgical treatment options for hyperhidrosis.

Non-surgical treatment of hyperhidrosis

Other therapies such as lasers, herbal medicines, microwave energy, and high-intensity ultrasound are not standard options in pediatrics and their efficacy has not been scientifically proven.

When patients do not respond to non-surgical alternatives, we offer a surgical treatment option.

Surgery for hyperhidrosis

Patients with primary hyperhidrosis have the option of undergoing a surgical procedure called thoracoscopic sympathectomy. The operation is also known as endoscopic thoracic sympathectomy or minimally invasive thoracic sympathectomy.

The sweat glands are stimulated by nerve fibers that arise from the spinal cord and run along each side of the spine in what is called the sympathetic chain. The thoracoscopic sympathectomy interrupts the sympathetic chain, preventing the nerve signals that originate in the spine from reaching and stimulating the sweat glands. This sympathetic chain is interrupted by cutting it, which is an irreversible procedure.

The sweat glands in each area of the body are controlled by nerves that arise at a specific level of the spine; therefore, the sympathetic chain must be interrupted only at the specific level that controls the affected areas. For primary hyperhidrosis of the hands, the sympathetic chain is interrupted at the level of the third to fourth rib.

Dr. Pablo Laje, a pediatric general surgeon at The Children’s Hospital of Philadelphia, offers surgery to children and teenagers who have primary focal hyperhidrosis of the hands, alone or in combination with armpits and/or feet. Patients whose hands are not involved are not candidates for the operation.

How is the surgery done and what should you expect?

The operation is performed in the operating room, under general anesthesia. Two tiny incisions are made in each armpit, which results in minimal postoperative pain and almost invisible scars. One of the incisions is used to place a very thin thoracoscope (similar to a small TV camera) and the other incision is used for the surgical instruments.

The operation takes approximately one hour for both sides. No drains or chest tubes are used, and the incisions don’t require any stitches that will need to be removed. The patient generally goes home the morning after the operation.

Outcomes

The operation is very effective in stopping hyperhidrosis of the hands, with consistent success rates above 95 percent. Patients who also have axillary (armpit) or plantar (foot) hyperhidrosis often experience improvement in these areas as well. The operation is more effective in children and adolescents than in adults.

Less than 1 percent of patients experience complications during or after the operation. Potential complications include pneumothorax, hemothorax, surgical site infection and Horner’s syndrome. Horner’s syndrome is a partial drooping of the eyelid and constriction of the pupil. It occurs when the sympathetic chain is interrupted at an inappropriately high level. The incidence of Horner’s syndrome is very low (less than 1 percent), and in most cases is temporary.

Compensatory sweating is a relatively common side effect (not a complication) of the thoracoscopic sympathectomy. Compensatory sweating is characterized by excessive sweating in areas of the body that were not affected prior to the operation, and the cause is unknown. The chest, the back and the thighs are the areas that can be affected by compensatory sweating. Compensatory sweating is much less common in children and teenagers than in adults. In most cases the compensatory sweating is mild or moderate, and very rarely is severe enough to cause as much discomfort as the previous sweating of the hands.

Comprehensive approach to care

At The Children’s Hospital of Philadelphia we are committed to treating the patient, not just the condition. The patient’s dermatologist, primary care physician and surgeon will work together to make sure that all treatment options are explored.

Patients who don’t have success with non-surgical options will be carefully screened through a comprehensive interview, a detailed self-assessment questionnaire, and a psychological evaluation to ensure that they are good candidates for surgery. Patients (and their families) who are appropriate candidates for the surgery will have an in-depth discussion with the surgeon about the risks and benefits of the operation. After the operation patients are followed on a regular basis in the surgery clinic.

Resources for families

Whether your child’s doctor has recommended surgery or you are seeking help, our team is available to answer any questions you may have about the procedure.

To learn more about surgery for hyperhidrosis or to refer a patient, contact the Division of Pediatric General, Thoracic and Fetal Surgery at 215-590-2730, or email us with any questions.

To learn more about the non-surgical options available to treat hyperhidrosis, visit our Division of Dermatology page or call 215-590-2169.

If your child is undergoing a surgical procedure at The Children’s Hospital of Philadelphia, we have a variety of resources available that can help you and your family prepare for the experience.

 

Created by: Mary Kate Klarich, MSN, CRNP
Reviewed by: Pablo Laje, MD
November 2013

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