Emerging treatments

CT scan-guided sympatholysis

CT scan-guided injection of phenol or alcohol into the sympathetic chain may permit nonsurgical sympathetic ablation.[55][56] One possible use may be in surgical failures from poor visibility due to lung adhesions or recurrence after initially successful surgery.

Endoscopic retroperitoneal lumbar sympathectomy

A minimally invasive technique for refractory plantar hyperhidrosis that involves lumbar sympathectomy.[57][58][59] It may be considered for patients with severe palmoplantar hyperhidrosis who have had thoracoscopic sympathectomy but continue to have troublesome plantar sweating. However, the procedure is associated with the possibility of increased compensatory sweating.

Noninvasive local thermolysis

Radiofrequency and ultrasound treatments show some promise for managing primary axillary hyperhidrosis.[16][22][23]​ They work by destroying eccrine sweat glands through thermolysis. Fractionated microneedle radiofrequency treatment significantly reduced the hyperhidrosis disease severity scale score compared with sham control in one study, but 46% of patients experienced relapse after 1 year.[60] A comparative study found fractionated microneedle radiofrequency treatment was less effective than transcutaneous onabotulinumtoxinA injection for primary axillary hyperhidrosis.[61] Focused ultrasound therapy uses high-intensity ultrasound to damage sweat glands. In one study, 92% of patients reported subjective improvement in sweat production.[62]

Botulinum toxin for non-axillary hyperhidrosis

Although onabotulinumtoxinA is approved only for axillary use in the US, it is often used off-label for other varieties of hyperhidrosis.[11][63][64]​​ Therefore, if symptoms do not resolve with aluminum chloride or iontophoresis, onabotulinumtoxinA injections may be considered. The injection process may be painful. However, local topical anesthetic may help.[11] For palmar hyperhidrosis, temporary muscle paralysis of the intrinsic muscles of the palms may occur following the injection. Efficacy and patient satisfaction are less with onabotulinumtoxinA than with endoscopic thoracoscopic sympathectomy.[65] Injections are less well tolerated for plantar hyperhidrosis due to the sensitivity of the soles of the feet compared with other areas of the body.

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