Palmar hyperhidrosis

January 30, 2012

Everyone sweats – but what if you had a condition that caused uncontrollable sweating in your hands?

Palmar hyperhidrosis is a benign condition where individuals experience uncontrollable sweating of their hands, way beyond their physiological needs. Hand sweating in such a scenario is often described as being present 24/7, may be worsened in situations of stress but also occurs out of nowhere in times of total rest and serenity. From the constant dampness the hands are exposed to, ulcerations and other skin related changes may develop. Many patients with this condition adopt a line of work and a life style that minimizes public encounters and avoid hand contact such as having to shake hands.

It has been known since the 1920s that by dividing the sympathetic chain (nerve) high up inside the chest, a procedure called thoracic sympathectomy, we can make the hands stop sweating. To achieve this surgically was quite an undertaking back then. The surgical trauma was such that historically very few individuals with hyperhidrosis opted to have corrective surgery. With the development of videoscopic surgery, however, it has become possible to perform the sympathectomy with minimal trauma to the patients. In addition, the magnification provided by the optics of videoscopic surgery has made the surgery safer.

What is involved in an ETS (Endoscopic Thoracic Sympathectomy)?

Nowadays, we offer surgery under general anesthesia as a day surgical procedure (meaning most patients are expected to go home the day of surgery). Two small incisions are needed, and we preferentially place those on your sides. At Swedish, our preferred approach is to clamp the nerve by placing titanium clips on the nerve at appropriate levels. The advantage of clipping the nerve instead of removing a segment of the nerve (as we did prior to 2005) is for possible reversal of the sympathectomy in the rare instance where a patient may be unhappy with the side effects of the surgery (see below).

What results should I expect?

In our hands, ETS will render the hands dry in 99 to 100% of cases. For many patients, their hands will become so dry that they will require the use of a moisturizing hand lotion for the rest of their life. A large number of individuals with palmar hyperhidrosis also experience excessive feet and/or armpits sweating. ETS targeting the hands will improve the feet sweating in 60% of cases, armpits sweating in up to 85%. The results are usually immediate and an eventual return of the hyperhidrosis is extremely rare.

Are there side effects?

The main side effect of ETS is a condition called “compensatory sweating” or CS where individuals may start experiencing uncontrollable sweating from other parts of their body. Most commonly, CS will affect the lower back, the lower abdomen, the groin and the back of the knees. In women, it may also develop under their breasts. One of the theories explaining the occurrence of CS is that it has been estimated that we all lose approximately 40% of our necessary body heat loss through our hands, arms and armpit areas. When one loses his or her ability to sweat from these areas, other areas have to “take over” otherwise that individual would die of “overheating”.

Though we cannot eliminate CS from happening entirely, there is evidence that by minimizing the extent of the sympathectomy performed we can lessen the severity of CS. For the rare individual who develops CS subjectively judged to be more severe than the presenting hyperhidrosis, reversal of the sympathectomy by removing the clips may be an option.


ETS is a minimally invasive surgical day surgery procedure where by applying titanium clips on the sympathetic nerves one can eliminate excessive hand sweating as seen in patients with palmar hyperhidrosis. In experienced hands, ETS is safe and offers great results with minimal morbidity.

Topics: Services, Surgery


How much of this surgury is out of pocket? Does one need a referral from their GP?
Hi Chuck,Thanks for your question. Out of pocket, a ballpark estimate is $20-25,000. You do not need a referral from your GP or PCP, although it is preferred. Feel free to call the clinic at 206-215-6800 with additional questions!
What is the age group for the kind of surgury.. I have a daugter who is near 16 and is very interested in it.. Her over sweating has really started to hold her back...
Hi Michelle, I touched base with Dr. Vallieres on your question - there is no age limit for this surgery. If the problem becomes a reason to cause someone to socially withdraw, the surgery should be seriously considered. If you'd like to make an appointment or if you have further questions, please call the clinic at 206-215-6800.
I had ETS about 10 years ago. It worked wonderfully for my hands but I still have issues with my feet. Is there any new information/surgical procedure that will help?Thank you.
Surgery for the feet is a possibility but is usually done by vascular surgeons and consists of a lumbar sympathectomy.However, before contemplating another level ETS, I would suggest that you trial wearing silver lined or copper lined socks. These can be found on Amazon. (I have also asked Dr. Tan, a vascular surgeon to weigh in regarding ETS)
We can do laparoscopic lumbar sympathectomy for hyperhidrosis of the feet. The results are good. Because it is done laproscopically the recovery is short.
Thank you so much for your responses. If I'm interested in the lumbar sympathectomy for hyperhydrosis of the feet, would it be best to schedule a consultation with Dr. Tan?Thanks again!
Holly, yes - you can call and schedule an appointment with Dr. Tan - her info is on her profile here:
Dr. Vallieres,I just wanted to say that you performed this operation on me in July 2006, and it has changed my life. Before I chose to undergo the surgery I hated the fact that my hands would sweat uncontrollably and it led to years of discomfort. Now I am more confident and comfortable in everyday life. I would recommend this procedure and your service to anyone dealing with excessive sweating. The results were immediate, the recovery time quick, and the side effects mnimal. Thanks again!
Is this surgery generally covered by insurance? My daughter plays a lot of competitive sports and her hand sweating interferes with her performance at times.
Some insurers cover it, others do not and some do not at first but if you fight it they will
I had ETS last year and the CS is unbearable- do you perform ETS reversal and if so, how effective is it?
Hi C Neller, ETS reversal may be reversible if the nerve was clipped for the ETS, not if it was divided or resected. The best results for reversal are when it is attempted within 3-4 months of the ETS. One year after the ETS however, the likelihood of successfully reversing the ETS are very low though not zero. Technically, the reversal (removal of the clips) is not more difficult at one year and yes I perform reversals when indicated.
Hello, I've been reading a lot of ETS. I suffer from pretty extreme facial blushing, it is very embarrassing and effects by personal and work life. I hate it. As I got older I thought it would go away but it definitely hasn't. I've tried beta blockers, therapy, etc but nothing helps. What would be the first step in order to get this procedure done?
Hi Chase, the first step would be to schedule an consult, you can do this by calling the clinic at 206-215-6800.