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Page 6 of 19 Gharagozloo et al. Mini-invasive Surg 2020;4:48 I http://dx.doi.org/10.20517/2574-1225.2020.35

with anticholinergic activity such as phenothiazines, antiparkinsonian drugs or tricyclic antidepressants,
intensify the antimuscarinic effects and can increase side effects. Relative contraindications to the use of
anticholinergics dugs are: glaucoma, obstructive uropathy, obstructive diseases of the GI tract, paralytic
ileus, severe ulcerative colitis, and myasthenia gravis.

[31]
Beta blockers have been used to improve symptoms of social phobias and performance anxiety .
Calcium channel blockers have also been used. The success of these techniques has been short-lived and
limited.

Iontophoresis which attempts to coagulate eccrine glands by the use of electrical current has been used for
palmar and plantar hyperhidrosis. This technique has had limited success [32,33] .

Botulinum toxin injection is the most studied hyperhidrosis treatment and demonstrates consistent
improvement in Hyperhidrosis Disease Severity Scale (HDSS) scores and in sweat production as measured
in the axillae and palms [34,35] . It may be considered first- or second-line therapy for hyperhidrosis affecting
the axillae, palms, soles, or face. Botulinum toxins bind synaptic proteins, blocking the release of
acetylcholine from the cholinergic neurons that innervate the eccrine sweat glands. The most commonly
used preparation is onabotulinumtoxinA (Botox). OnabotulinumtoxinA is administered intradermally in
the affected area. In most cases, treatment results last six to nine months. Adverse effects typically include
injection-site pain and bruising, decreased grip strength when injected into the palms, and frontalis muscle
weakness when used on the forehead.

[36]
A newer, noninvasive local treatment of axillary hyperhidrosis uses microwave technology . The
application of microwave energy destroys eccrine sweat glands by creating local heat, resulting in cellular
thermolysis. This outpatient procedure is applied with a handheld transducer after mapping the axillae
using a starch-iodine test. Local anesthesia is required. This treatment results in a decrease in the HDSS
score of at least one point in 94% of patients and at least two points in 55% of patients .
[37]

[38]
Fractionated microneedle radiofrequency is another emerging treatment in axillary hyperhidrosis .
During this procedure, microneedles are placed 2 to 3 mm under the skin, and radiofrequency energy
is applied. This therapy results in a decrease in the HDSS score of at least one point in nearly 80% of
[39]
patients .

Alternative surgical therapies
Surgical alternatives such as resection of the axillary sweat glands or subcutaneous curettage have been
limited only to axillary hyperhidrosis. However, these techniques have had little acceptance due to the
highly invasive nature of the procedures and the high complication rates and high relapse rates several
months after the procedure [40,41] .

Dorsal thoracic sympathectomy
Nonsurgical methods for accomplishing dorsal thoracic sympathectomy have included: (1) percutaneous
injection of phenol; (2) CT-guided injection of phenol; and (3) percutaneous radiofrequency thermal
ablation [42-45] . These techniques have been hampered by very high recurrence rates shortly after the
procedure. Dorsal sympathectomy has been the only treatment for hyperhidrosis that has resulted in long-
term success.

Many surgical approaches have been described for dorsal thoracic sympathectomy. These have included:
(1) the posterior thoracic approach; (2) cervical supraclavicular approach; (3) transthoracic approach; (4)
transaxillary approach; (5) thoracoscopic approach; and (6) robotic thoracoscopic approach.