The long-term safety and efficacy of 52-week application of oxybutynin hydrochloride 20% lotion (20% OL) for the treatment of primary palmar hyperhidrosis (PPHH) in Japanese patients aged ≥12 years were evaluated in an open-label extension (OLE) of a 4-week, randomized, double-blind (DB) study. The OLE included 114 patients who completed the DB study and wished to continue treatment and 12 new patients. In the safety analysis population (125 patients), the incidence of adverse events (AEs) and adverse drug reactions (ADRs) was 79.2% and 36.0%, respectively. Serious AEs were observed in two patients but were considered unrelated to the investigational drug. The incidence of AEs that led to study discontinuation was 1.6%. The incidence of application site AEs and ADRs was 35.2% and 26.4%, respectively. The severity of most events was mild. The incidence of anticholinergic AEs related to dry mouth was 3.2% for thirst and 0.8% for dry throat. The long-term efficacy of 20% OL was confirmed by a long-lasting reduction in sweat volume and improvement in the Hyperhidrosis Disease Severity Scale and Dermatology Life Quality Index. This study has several limitations: First the results may include some bias because most of the participants were from the prior DB study; second, the results may not be generalizable because only a few participants were in the age group most susceptible to PPHH (i.e., < 15 years old); and third, the study did not obtain safety information from treatment for more than 52 weeks, so this information must be collected in clinical practice in the future. No reduced therapeutic effect was observed in patients with PPHH in this study after 52-week application of 20% OL. Also, few patients experienced serious AEs or AEs that led to study treatment discontinuation.

BACKGROUND: The regulatory effect of integrin β6 (ITGB6) on sweat gland cells in primary palmar hyperhidrosis (PPH) remains unclear.
OBJECTIVE: This study investigated the involvement of ITGB6 in the pathogenesis of PPH.
METHODS: Sweat gland tissues were collected from PPH patients and healthy volunteers. The expression levels of ITGB6 in sweat gland tissues were detected with quantitative polymerase chain reaction (qPCR), western blot and immunohistochemical staining. Sweat gland cells were extracted from PPH patients, and identified with immunofluorescence staining of CEA and CK7. The expression of aquaporin 5 (AQP5) and Na-K-Cl cotransporter 1 (NKCC1) in primary sweat gland cells that overexpress ITGB6 were also detected. Through a series of bioinformatic methods, differentially expressed genes in sweat gland tissues were examined and validated via comparing PPH samples and controls. The key proteins and biological functions enriched in PPH were determined using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses.
RESULTS: The ITGB6 was upregulated in sweat gland tissues of PPH patients compared to that of healthy volunteers. The CEA and CK7 were positively expressed in sweat gland cells extracted from PPH patients. The overexpression of ITGB6 upregulated AQP5 and NKCC1 protein expression in the sweat gland cells of PPH patients. A total of 562 differentially expressed mRNAs were identified using high-throughput sequencing (394 upregulated, 168 downregulated), which were mainly active in the chemokine and Wnt signaling pathways. After verification with qPCR and western blot, the overexpression of ITGB6 significantly upregulated CXCL3, CXCL5, CXCL10, and CXCL11, and downregulated Wnt2 mRNA and protein expression in sweat gland cells.
CONCLUSIONS: The ITGB6 is upregulated in PPH patients. It may be involved in the pathogenesis of PPH by upregulating AQP5, NKCC1, CXCL3, CXCL5, CXCL10, and CXCL11, and downregulating Wnt2 expression in sweat glands.

The results and side effects of sympathicotomy for primary palmar hyperhidrosis (PPH) can vary due to anatomical variations of the sympathetic ganglions. The aim of our study was to clarify anatomical variations of the sympathetic ganglions by near-infrared (NIR) thoracoscopy and determine their effects on sympathicotomy for PPH.
The cases of 695 consecutive patients with PPH treated with either R3 or R4 sympathicotomy either by normal thoracoscopy or by NIR fluorescent thoracoscopy between March 2015 and June 2021 were retrospectively reviewed and followed up.
The variation rate of third and fourth ganglions was 14.7% and 13.3% on the right side and 8.3% and 11.1% on the left side. Real T3 sympathicotomy (RTS3) was more effective than real T4 sympathicotomy (RTS4) in the short-term and long-term follow-up (p < 0.001 and p < 0.001, respectively). RTS3 was more satisfactory than RTS4 in the long-term follow-up (p = 0.03), but no significant difference was found in the short-term follow-up (p = 0.24). The incidence and severity of compensatory hyperhidrosis (CH) in the areas of the chest and back in the RTS4 group were significantly lower than those in the RTS3 group according to both the short-term results (12.92% vs. 26.19%, p < 0.001; 17.97% vs. 33.33%, p = 0.002, respectively) and the long-term results (19.66% vs. 28.57%, p = 0.017; 21.35% vs. 34.52%, p < 0.001, respectively).
RTS3 may be more effective than RTS4 for PPH. However, RTS4 appears to be associated with a lower incidence and severity of CH in the areas of the chest and back than RTS3. NIR intraoperative imaging of thoracic sympathetic ganglions may improve the quality of sympathicotomy surgeries.

No previous controlled studies have been specifically designed or adequately powered to show the efficacy of topical oxybutynin for palmar hyperhidrosis by using quantitative measures.
To evaluate efficacy of 20% oxybutynin hydrochloride lotion (20% OL) in reducing palmar sweat volume in patients with primary palmar hyperhidrosis (PPHH).
In a randomized controlled trial, Japanese patients with PPHH aged 12 years and older received either 20% OL (n = 144) or placebo (n = 140) on both palms once daily for 4 weeks. Palmar sweat volume was measured by the ventilated capsule method. For the primary outcome, response was defined as a reduction of sweat volume of at least 50% from baseline.
At week 4, the responder rate for sweat volume was significantly higher in the 20% OL arm than in the placebo arm (52.8% vs 24.3%, respectively; treatment difference, 28.5% [95% CI, 17.7% to 39.3%]; P < .001). No serious adverse events occurred, and no adverse events led to treatment discontinuation.
The treatment period was only 4 weeks.
In patients with PPHH, 20% OL is superior to placebo in reducing palmar sweat volume.

UNASSIGNED: Endoscopic thoracoscopic sympathectomy (ETS) is the preferred method for treating primary palmar hyperhidrosis (PPH) that bears the risk of compensatory hyperhidrosis (CH) following surgery. The current study aims to evaluate the effectiveness and safety of an innovative surgical procedure of ETS.
UNASSIGNED: A survey of the clinical data of 109 patients with PPH who underwent ETS in our department from May 2018 to August 2021 was retrospectively conducted. The patients were organized into two groups. Group A underwent R4 sympathicotomy combined with R3 ramicotomy. Group B underwent R3 sympathicotomy. Patients were followed up to evaluate the safety, effectiveness and the incidence of postoperative CH of the modified surgical approach.
UNASSIGNED: A total of 102 patients completed follow-up, and seven of the total enrolled patients were lost to follow-up, with a loss rate of 6% (7/109). Among these, Group A constitutes 54 cases, group B constitutes 48 cases, and the mean follow-up was 14 months (interquartile range 12-23 months). There was no statistically difference in surgical safety, postoperative efficacy, and postoperative quality of life (QoL) score between group A and group B (p > 0.05). The score of the psychological assessment was higher (p = 0.004) in group A (14.15 ± 2.06) compared to group B (13.30 ± 1.86). The incidence of CH in group A was lower than in group B (p = 0.019).
UNASSIGNED: R4 sympathicotomy combined with R3 ramicotomy is safe and effective for PPH treatment, along with a reduced incidence of postoperative CH rate and improved postoperative psychological satisfaction.

Postoperative diaphragmatic hernia (DH) following endoscopic thoracic sympathectomy for primary palmar hyperhidrosis is extremely rare. We present a 21-year-old female patient who developed a left DH with herniation of the stomach and gastric perforation on the first postoperative day after undergoing bilateral video-assisted thoracoscopic sympathectomy R4 ablation. She complained of severe dyspnea and chest pain, and an emergency chest x-ray and computed tomography revealed left pleural effusion, collapsed lung, and left DH, which allowed the stomach to herniate into the chest. Emergency thoracoscopic surgery was performed. We repaired the diaphragmatic defect intraoperatively and replaced the stomach with the peritoneal cavity from the thoracic field. The patient was discharged without complications. She did not present with recurrent symptoms at the 3-month follow-up. Postoperative DH should be considered when patients complain of gastrointestinal or respiratory symptoms after sympathectomy, although it is very rare.

Primary palm hyperhidrosis (PPH) is a chronic disease characterized by uncontrolled palm-sweating exceeding physiological needs. It negatively impacts the quality of life of the patients and can lead to different degrees of psychological problems. Currently, there are a variety of treatment options for PPH, of which thoracotomy is a first-line treatment that has shown good efficacy. However, since it is an invasive procedure requiring general anesthesia and is often associated with high costs and serious complications, better alternatives should be explored. Computed tomography (CT)-guided percutaneous puncture of radiofrequency thermocoagulation (RF-TC) of the thoracic sympathetic nerve is a promising alternative treatment. It is a minimally invasive procedure that can be performed under local anesthesia and is associated with rapid recovery. However, the factors affecting the duration of the surgery-related benefits and outcomes of CT-guided percutaneous RF-TC of the thoracic sympathetic nerve are unclear.
To investigate the factors influencing the outcomes of CT-guided percutaneous RF-TC of the thoracic sympathetic nerve in patients with PPH.
A retrospective study.
This study was conducted at the Pain Department of Jiaxing University Affiliated Hospital (Jiaxing, China).
After approval by the Ethics Committee of the Affiliated Hospital of Jiaxing College, the data of 232 corresponding patients were assessed. The Kaplan-Meier method was used for survival analysis. Univariate and multivariate analyses were performed to identify factors associated with PPH and to construct a nomogram for predicting postoperative recurrence. Time-independent receiver operating characteristic (ROC) curve analyses were performed to assess the nomogram\'s predictive capacity.
In the one-year survival analysis model, gender (HR = 1.573, 95%CI: 0.844 to 2.934), age (HR = 0.965, 95%CI: 0.915 to 1.018), disease course (HR = 0.960, 95%CI: 0.908 to 1.015), palm temperature difference (HR = 0.377, 95%CI: 0.287 to 0.495), perfusion index difference (HR = 0.590, 95%CI: 0.513 to 0.680) and hyperhidrosis disease severity scale (HR = 1.963, 95%CI: 0.769 to 5.011) were identified as statistically significant factors in univariate analysis, while palm temperature difference (HR = 0.589, 95%CI: 0.369 to 0.941) and perfusion index difference (HR = 0.357, 95%CI: 0.588 to 0.968) were the independent factors in the multivariate Cox proportional hazards risk model. In the 2-year survival analysis model, palm temperature difference (HR = 0.353, 95%CI: 0.261 to 0.478), perfusion index difference (HR = 0.589, 95%CI: 0.510 to 0.680) and hyperhidrosis disease severity scale (HR = 1.964, 95%CI: 0.771 to 5.006) were the statistically significant factors while palm temperature difference (HR = 0.507, 95%CI: 0.321 to 0.799) and perfusion index difference (HR = 0.789, 95%CI: 0.625 to 0.995) were the independent factors.
This single-center retrospective study was limited by its small sample size, short follow-up time, and the possibility of bias resulting from the non-random patient selection.
Palm temperature difference and perfusion index difference were independent risk factors associated with prolonging the surgical benefits and reducing postoperative recurrence of CT-guided RF-TC of the sympathetic nerves in patients with PPH.

Our study examined attitudes towards initial management of hyperhidrosis, willingness to seek surgical consultation and knowledge of an appropriate specialty for surgical consultation among primary care physicians and the general public.
An online survey was sent to all general medicine and paediatric residents and attending physicians at our academic medical centre. Participants were provided with a clinical scenario of palmar hyperhidrosis and were asked to select among initial management options and preferences for surgical consultation if patients failed non-operative management. To assess the general public\'s perspective, workers from Amazon Mechanical Turk were recruited to complete a similar survey.
The majority of primary care physicians (31/53; 58%) would prescribe topical aluminium chloride for palmar hyperhidrosis, whereas 28 of 53 (53%) would refer such patients to dermatology. Twenty-three of 53 (43%) physicians would refer such patients to surgery if conservative management failed: 18 (78%) to plastic surgery, 4 (17%) to general surgery and none to thoracic surgery. The majority of workers (130/205; 63.4%) would seek primary care treatment for palmar hyperhidrosis. Over half (113/205; 55%) would seek surgical consultation if conservative management failed: 65 (58%) general surgery and 15 (13%) neurosurgery, with only 8 (7%) selecting thoracic surgery.
Neither primary care physicians nor the general public recognize the role of thoracic surgeons in managing primary focal hyperhidrosis when medical management fails. Education of physicians and the public may mitigate this knowledge gap.

BACKGROUND: Primary palmar hyperhidrosis (PPH) is a disorder related to sympathetic dysfunction. Iontophoresis can be used to reduce sweating rate. Sympathetic skin response (SSR) is commonly used to evaluate the sympathetic system. However, scarce evidence exists about the reliability of SSR parameters.
OBJECTIVE: To assess the relative and absolute reliability of SSR before and after the application of iontophoresis with aluminum chloride hexahydrate (ACH) gel or tap water in subjects with PPH.
METHODS: Twenty subjects were randomized to receive either iontophoresis with ACH gel or tap water. Three SSRs (amplitude and latency) with 5 s intervals from both hands in both groups were recorded before and after the application of iontophoresis for 30 min. Reliability of amplitude and latency of the SSR was assessed using intraclass correlation coefficient (ICC) with 95% confidence intervals, standard error of measurement (SEM), and minimal detectable change (MDC).
RESULTS: Amplitudes and latencies of SSR showed good to excellent test-retest reliability for ICC in both groups before iontophoresis. Except for right hand latency which was moderate (0.5-0.75). After iontophoresis, the ACH gel group still showed good to excellent agreement for SSR parameters, while the reliability of SSR parameters in the tap water group was reduced.
CONCLUSIONS: Subjects with PPH showed high intra-rater reliability for SSR parameters which was maintained after ACH gel iontophoresis and decreased after tap water iontophoresis. It seems that media used for iontophoresis or the state of media (gel vs liquid) may affect the reliability of SSR. Further research is recommended.

Intradermal injections of botulinum toxin type A (BTX-A) have been used successfully to treat patients with primary palmoplantar hyperhidrosis (PPH). However, problems with local injections of BTX-A for palmar hyperhidrosis include injection pain and reduced palmar muscle strength. This case series describes three patients with PPH. Patients were followed up for 3 months and assessed using the minor iodine starch test and the visual analog scale (VAS). Over two sessions within a 2-week interval, all patients received treatment on one palm, while the other palm served as the untreated control. Treated palms received fractional CO2 laser therapy and immediate post-operative topical application of BTX-A solution for a total of 50 units. Sweat production was assessed based on the size of the sweat-producing area (measured by the minor iodine starch test) and subjective assessment of sweat production using the visual analog scale (VAS) at baseline, 2 weeks after the first treatment, and 1, 2, and 3 months after the second treatment. In the BTX-A-treated palm, the decrease in the mean sweat production was 51.6% at 2 weeks after the first treatment, and 88.5%, 67.8%, and 52.9%, at 1, 2, and 3 months after the final treatment when compared to the baseline. In the untreated palms, the decrease in the mean sweat production was 2% on all follow-ups when compared to the baseline. No adverse effect was observed in any patient. Fractional CO2 laser is a safe technique for BTX-A delivery on the palm area and is demonstrated to be safe and effective in decreasing sweat secretion of hyperhidrosis palm.