Medicine Section - Surgical Treatments for Hyperhidrosis

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description

Hyperhidrosis may be defined as excessive sweating, beyond a level required to maintain normal body temperature in response to heat exposure or exercise. Hyperhidrosis can be classified as either primary or secondary. Primary localized hyperhidrosis is idiopathic in nature, typically involving the hands (palmar), feet (plantar), or underarms (axillae).  Primary focal hyperhidrosis is defined as bilateral, relatively symmetric, excessive sweating of at least six months’ duration induced by sympathetic hyperactivity in selected areas that is not associated with an underlying disease process. The most common locations are underarms (axillary hyperhidrosis), palms (palmar hyperhidrosis), soles of the feet (plantar hyperhidrosis) or face and scalp (craniofacial hyperhidrosis). The second (T2) and third (T3) thoracic ganglia are responsible for palmar hyperhidrosis, the fourth (T4) thoracic ganglia controls axillary hyperhidrosis, and the first (T1) thoracic ganglia controls facial hyperhidrosis.

Secondary hyperhidrosis is usually generalized or craniofacial sweating.  It can result from a variety of drugs, such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), olfactory stimuli, or underlying diseases/conditions, such as febrile diseases, diabetes mellitus, anxiety, menopause, neurologic lesions, intrathoracic neoplasms, Raynaud’s disease, Frey’s syndrome.  Secondary gustatory hyperhidrosis is excessive sweating on ingesting highly spiced foods.  This trigeminovascular reflex typically occurs symmetrically on scalp or face and predominately over forehead, lips and nose. Secondary facial gustatory sweating, in contrast, is usually asymmetrical and occurs independently of the nature of the ingested food. This phenomenon frequently occurs after injury or surgery in the region of the parotid gland. Frey’s syndrome is an uncommon type of secondary gustatory hyperhidrosis that arises from injury to or surgery near the parotid gland resulting in damage to the secretory parasympathetic fibers of the facial nerve. After injury, these fibers regenerate and miscommunication occurs between them and the severed postganglionic sympathetic fibers that supply the cutaneous sweat glands and blood vessels. The aberrant connection results in gustatory sweating and facial flushing with mastication. Aberrant secondary gustatory sweating follows up to 73% of surgical sympathectomies and is particularly common after bilateral procedures.

The consequences of hyperhidrosis are primarily psychosocial in nature. Excessive sweating may be socially embarrassing or may interfere with certain professions. Symptoms such as fever, night sweats, or weight loss require further investigation to rule out secondary causes.  Sweat production can be assessed with the minor starch iodine test, which is a simple qualitative measure to identify specific sites of involvement.

A variety of medical therapies have been investigated for treating primary hyperhidrosis, including topical therapy with aluminum chloride or tanning agents, iontophoresis, intradermal injections of botulinum toxin Type A.  Treatment of secondary hyperhidrosis naturally focuses on treatment of the underlying cause.

This medical policy addresses only surgical treatment of hyperhidrosis. Surgical treatments for axillary hyperhidrosis include transthoracic sympathectomy and surgical excision of axillary sweat glands. Transthoracic sympathectomy may also be used for palmar hyperhidrosis. Surgical removal of axillary sweat glands has been performed in patients with severe isolated axillary hyperhidrosis. Removal may involve removal of the subcutaneous sweat glands without removal of any skin, limited excision of skin and removal of surrounding subcutaneous sweat glands or a more radical excision of skin and subcutaneous tissue en bloc.

A variety of approaches have been reported for transthoracic sympathectomy, but transthoracic endoscopic techniques have emerged as minimally invasive alternatives to transaxillary, supraclavicular, or anterior thoracic approaches. Lumbar sympathectomy may be performed as a surgical treatment of plantar hyperhidrosis and may also be done endoscopically.

While accepted as an effective treatment, sympathectomy is not without complications. In addition to the immediate surgical complications of pneumothorax or temporary Horner's syndrome, compensatory sweating on the trunk can occur in up to 55% of patients, reducing patient satisfaction with the procedure. Gustatory sweating may also occur. Sympathectomy also results in cardiac sympathetic denervation, which in turn can lead to a 10% reduction in the heart rate.  In addition to the complications associated with transthoracic sympathectomy, lumbar sympathectomy for plantar hyperhidrosis may have the additional risk of permanent sexual dysfunction in men and women.

Tympanic neurectomy is a surgical technique that may be used for treatment of severe gustatory hyperhidrosis.  The nerves are transected in the middle ear through a flap created in the ear drum.  Possible risks from this surgery include rupture of tympanic membrane, infection, hearing loss, and loss of taste in certain parts of the tongue.

Policy/Criteria

Position Statement

Endoscopic Transthoracic Sympathectomy (ETS)

The evidence is sufficient to suggest that ETS may be effective for severe, refractory axillary and palmar hyperhidrosis.

Large case series on ETS have reported success rates for of up to 98% for treatment of axillary and/or palmar hyperhidrosis. (2-8)

One randomized, controlled comparative trial reported primary success rates of 96.3% for isolated palmar hyperhidrosis, 95.7% for palmar and axillary hyperhidrosis, and 66.7% for palmar and face/scalp hyperhidrosis. (9) Complication rates were similar among the groups and included pneumothorax which required no intervention.

Lumbar Sympathectomy

Due to the lack of clinical trial data, the evidence is insufficient to determine whether lumbar sympathectomy is safe and effective for any indication.

Surgical Removal of Axillary Sweat Glands (including Liposuction and curettage)

There is sufficient evidence to suggest that excision of sweat glands may be safe and effective as a treatment of severe, refractory axillary hyperhidrosis. (10)

There is insufficient evidence to determine whether liposuction or curettage of sweat gland is safe or effective as a treatment of axillary hyperhidrosis. Although this procedure has been performed for several decades, only scattered reports regarding its effectiveness were identified in a MEDLINE literature search. (11-15)

Axillary Subdermal Laser Treatment

The evidence is insufficient to determine the impact of subdermal laser-assisted axillary hyperhidrosis treatment on clinical outcomes.

The evidence consists of one small (n=17) pilot study with eight weeks followup which reported good or excellent results in 82% of patients. (16)

References

1. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 8.01.19
2. Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: An efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol 1995;33(1):78-81
3. Shachor D, Jedeikin R, Olsfanger D et al. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies. Arch Surg 1994;129(3):241-4
4. Gossot D, Galetta D, Pascal A et al. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg 2003;75(4):1075-9
5. Leseche G, Castier Y, Thabut G et al. Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory sweating. J Vasc Surg 2003;37(1):124-8
6. Atkinson JL, Fealey RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc 2003;78(2):167-72
7. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery 2002;51(5 suppl):84-7
8. Han PP, Gottfried ON, Kenny KJ et al. Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis. Neurosurgery 2002;50(2):306-12
9. Inan K, Goksel OS, Uçak A et al. Thoracic endoscopic surgery for hyperhidrosis: comparison of different techniques. Thorac Cardiovasc Surg 2008;56(4):210-3
10. Hafner J, Beer GM. Axillary sweat gland excision. Curr Probl Dermatol 2002;30:57-63
11. Park S. Very superficial ultrasound-assisted lipoplasty for the treatment of axillary osmidrosis. Anesthetic Plast Surg 2000;24(4):275-9
12. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg 2001;27(5):446-8
13. Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique. Dermatol Surg 2000;26(4):392-6
14. Shenaq SM, Spira M, Christ J. Treatment of bilateral axillary hyperhidrosis by suction-assisted lipolysis technique. Ann Plast Surg 1987;19(6):548-51
15. Ong WC, Lim TC, Lim J et al. Suction-curettage: treatment for axillary hyperhidrosis and hidradentitis. Plast Reconstr Surg 2003;111(2):958-9
16. Goldman A, Wollina U. Subdermal Nd-YAG laser for axillary hyperhidrosis. Dermatol Surg. 2008;34(6):756-62

Cross References

Botox® botulinum toxin Type A injection, Regence Medication Policy Manual, Drugs, Policy No. 006

Regence Consumer Tx, Surgery for Hyperhidrosis (Excessive Sweating)

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