Primary palmar hyperhidrosis is a common disorder

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1 Bilateral Thoracoscoic T2 to T3 Symathectomy Versus Injection in Palmar Hyerhidrosis Vincenzo Ambrogi, MD, Elena Camione, MD, Davide Mineo, MD, Evelin Jasmine Paternò, MD, Eugenio Pomeo, MD, and Tommaso C. Mineo, MD Divisions of Thoracic and Dermatology, Policlinico Tor Vergata University, Rome, Italy Background. Bilateral T2 to T3 thoracoscoic symathectomy and injection of botulinum toxin-a are resently the most effective modalities in the treatment of rimary almar hyerhidrosis. In this study we evaluated comarative merits of the two theraies. Methods. Patients suffering rimary almar hyerhidrosis were treated by either bilateral T2 to T3 thoracoscoic symathectomy () or by injection of botulinum toxin-a (). The grous were homogeneous for relevant demograhic, hysiologic, and clinical data. Quantification of sweat roduction was erformed by Minor s iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyerhidrosis, Dermatology Life Quality Index, Short Form-36, Nottingham s Health Profile) and atient s satisfaction self-assessment. A cost comarison between grous was also carried out. Results. No oerative mortality or major morbidity was recorded in either grou. Minor s test showed a more significant reduction in the surgical grou: 94% versus 63% at 6 months and 94% versus 30% at 12 months. Comensatory sweating was significantly greater and long-lasting in the surgical grou. All subjective tests imroved raidly and significantly in both grous. After 6 months, results mildly worsened in the surgical grou and more significantly in the botulinum grou. Patient s satisfaction was initially greater in the botulinum grou ( 0.03), but after 6 months it significantly reversed ( 0.04). Surgical treatment cost aroximately as much as four botulinum treatments. Conclusions. Thoracoscoic symathectomy is suerior to botulinum toxin-a injection. The greater initial costs and discomfort are offset by a greater reduction in comensatory sweating. (Ann Thorac Surg 2009;88:238 45) 2009 by The Society of Thoracic Surgeons Primary almar hyerhidrosis is a common disorder characterized by excessive sweating of the alms. It is a disabling condition, causing social as well as sychological and occuational roblems. The excessive sweat is mediated by the vegetative nervous system and often begins rimarily at the level of the uer extremities, but may involve lantar surfaces as well as the axilla. The degree of sweating may reach the status of clear driing and be aggravated by stress and anxiety, thus resulting in a sychological, social, and rofessional burden for such atients [1 3]. The surgical interrution of the suerior thoracic symathetic chain through a thoracoscoic aroach is believed to be the best treatment and is widely adoted by the majority of thoracic surgical centers worldwide because of its safety and ability to achieve definitive cure [4 7]. toxin-a injection is a romising new theraeutic otion for hyerhidrosis that is administered on an outatient basis, with minimal adverse reactions, low invasiveness, and high efficacy [8 10]. However, the duration of the effect of botulism is usually limited to about 6 to 12 months [8]. This study evaluated immediate and mid-term results achieved by the two different treatments in a series of selected atients from a Acceted for ublication Aril 1, Address corresondence to Dr T. Mineo, Cattedra di Chirurgia Toracica, Università Tor Vergata, Policlinico Tor Vergata, Via Oxford, 81, Rome, 00133, Italy; mineo@med.uniroma2.it. single center to demonstrate comarative merits and incidence of comlications as well as economic imact. Material and Methods The study was aroved by the investigation review board and ethical commission of our institution. All atients gave fully informed written consent. Patients Between November 2001 and December 2007, 154 consecutive atients (91 women), ranging in age from 20 to 45 years (median, 30 years; interquartile range, 26 to 33 years) exhibiting rimary almar hyerhidrosis entered the study. All atients had severe almar hyerhidrosis since childhood and were socially, rofessionally, and sychologically handicaed. Almost two thirds of them (64.2%) had failed to imrove their symtoms with conservative local (ie, antiersirants) and systemic agents (ie, anticholinergic, -blockers, anxiolytic, antideressant drugs) or iontohoresis. Study Design The study was designed as a rosective and comarative (surgery versus botulinum) investigation. All atients were given the choice between undergoing bilateral T2 to T3 one-stage thoracoscoic symathectomy 2009 by The Society of Thoracic Surgeons /09/$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg AMBROGI ET AL 2009;88: TREATMENTS OF PALMAR HYPERHIDROSIS 239 Table 1. Demograhic and Clinical Characteristics of Patients After Symathectomy () and Toxin-A Injection () for Palmar Hyerhidrosis a Variable () () Sex (male/female) 28/40 35/ Median age (y) Family history (yes/no) 40/28 38/ Previous resiratory disease (%) FEV 1 % redicted Previous treatment (yes/no) 46/22 53/ a Data reorted as mean standard deviation. FEV 1 forced exiratory volume in 1 second. () or botulinum toxin-a injection (). Patients gave their consent after having been fully informed about the more frequent side effects of each rocedure, such as comensatory sweating and esecially those after surgery: interscaular ain, transient neumothorax, and Horner s syndrome. Crossover from one grou to another was authorized after a minimum eriod of 1 year from the beginning of the treatment. However, these atients were not considered as art of the new grou. As already stated, the study was aroved by the secific institutions. Objective Sweating Assessment Objective assessment was erformed by Minor s iodine starch test [11] and ad glove test [12]. Minor s iodine starch test is a diagnostic criterion erformed by ainting the affected surface with iodine staining and waiting for it to dry. This area is subsequently owdered with starch, which renders visible the sweating reaction. The starch iodine combination turns a dark blue color wherever there is excessive sweat. Test results were quantified by a digital hotograh of both hands taken 5 minutes after owder alication at a steady distance of 0.70 meters. The image was then rocessed with grahic software (Photosho CS4, Adobe System Inc, San Jose, CA). The mean intensity of sweating for the entire alm surface, directly roortional to the alm brightness in the icture, was scored according to a modified gray scale rovided by the same software. It attributed the value 0 (black) to the maximum sweating and 240 (white) to the minimum. To also objectively determine comensatory sweating the test was reeated before and eriodically after treatment in axilla, facial, lumbar, and lantar regions. Pad gloves of adequate size made from gauze material and surgical gloves were reared and weighed on an electronic scale with gram sensitivity (Mettler P1210, Instrumente AG, Zurich, Switzerland). The atients then ut on the ad gloves and then surgical gloves over these. They waited in a comfortable, stress-free room for 1 hour. The temerature and humidity of the room ranged between 19 and 22 C and 45% and 55%, resectively. At the end of this eriod, we carefully removed the Table 2. Objective Tests After Symathectomy () and Toxin-A Injection () for Palmar Hyerhidrosis a Baseline s 1-Month % Changes 3-Month % Changes 6-Month % Changes 12-Month % Changes n 70 n 59 Tests d 90 d d 75 d d 63 d d 30 c Palmar Minor (gray scale 0 240) Pad (g/h) d 69 d d 45 c d 34 c d 29 c Temerature ( C) c 36 c c 15 b c c a Baseline values are reresented as mean standard deviation. Intragrou significance with baseline values: b 0.05, c 0.01, d

3 240 AMBROGI ET AL Ann Thorac Surg TREATMENTS OF PALMAR HYPERHIDROSIS 2009;88: gloves, to avoid sweat evaoration, and immediately reweighed them. Differences between initial and final measurements of both gloves were noted in terms of grams er hour for sweat intensity of the hands. Temerature of the forefinger in a 20 C room was also determined starting from 1 hour after treatment using a fluorotic thermometer. Subjective Sweating and Quality of Life Assessment Subjective sweating changes were assessed by the Hyerhidrosis Quality of Life Questionnaire [2] and the Dermatology Life Quality Index [13]. Hyerhidrosis quality of life questionnaire [2] evaluates with 20 questions (subjectively scored from 1 oor to 5 high) the quality of life during actions influenced by sweating; at hot temeratures, under hysical or emotional stress, and during social, working, and sexual activities. A final cumulative score was obtained by adding the score for each single question (maximum 100, minimum 20). The questionnaire was not only focused on almar hyeridrosis and thus comensatory sweating could be taken into account. The Dermatology Life Quality Index [13] consists of 10 questions investigating the imact of dermatologic roblems on symtoms and feelings, daily activities, leisure, work and school, ersonal relationshis, and treatment. The score is calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0; the higher the score, the more quality of life is imaired. Just as the revious one, this questionnaire considers comensatory sweating. General health status was evaluated by the Short Form-36 (SF-36) [14] and the Nottingham Health Profile [15] questionnaires. These questionnaires were chosen because of their relative simlicity and availability in validated versions for the Italian oulation [16, 17]. Furthermore, values of a normative same-age and samesex Italian oulation were available and they were matched with baseline data of our study samle. The Nottingham Health Profile [14, 16] contains 38 dichotomic-choice questions (ositive-negative) relating to six health domains (mobility, energy, ain, social isolation, slee disturbance, and emotional reactions). The Short Form 36-item, [15, 17] consists of 36 multilechoice questions that cover eight health concets (hysical functioning, social functioning, hysical role, emotional role, vitality, bodily ain, mental health, general health ercetion) and two main cumulative summaries (hysical and mental). Symathectomy All atients were given the choice between undergoing general anesthesia with double-lumen intubation (n 35) or eidural anesthesia (n 29). The remaining 4 atients were initially aroached through eidural anesthesia and thereafter converted to general anesthesia because of intolerance of neumothorax (n 2) or anxiety (n 2). The oeration was a one-stage, two-ort, T2 to T3 bilateral thoracoscoic symathectomy with atients laced in Table 3. Subjective Tests After Symathectomy () and Toxin-A Injection () for Palmar Hyerhidrosis a Baseline s 1-Month % Changes 3-Month % Changes 6-Month % Changes 12-Month % Changes n 58 n 74 n 63 n 80 Subjective Questionnaire d 214 d d 183 d d 85 c c Hyerhidrosis Quality of Life cumulative score (0 min 100 max) d 83 d d 80 d d 48 c c 17 b Dermatology Life Quality Index cumulative score (0 max 30 min) a Baseline values are reorted as mean standard deviation. Intragrou significance with baseline values: b 0.05, c 0.01, d

4 Ann Thorac Surg AMBROGI ET AL 2009;88: TREATMENTS OF PALMAR HYPERHIDROSIS 241 Fig 1. Comensatory sweating after both treatments (symathectomy, continuous line; botulinum injection, dotted line) measured as mean ercentage increment from the baseline by Minor s test in different body areas. Intergrou robability values are indicated when significant. connected to mild suction while the atient s osition was changed to allow aroach on the other side. Toxin-A Injection toxin-a (Botox; Allergan Inc, Irvine, CA) was always administered in a unique session. One amule of Botox (100 U) was diluted with 5 ml of nonconserved sterile hysiologic saline solution, resulting in a concentration of 2 units er 0.1 ml of solution. After regional median and ulnar nerve block with infiltration of roivacaine 0.75%, botulinum toxin-a was injected intradermally in 28 sites in each alm in the same session, using 1-mL tuberculin syringes and 27- gauge needles. A total amount of 0.1 ml equivalent to 2 units was injected in each of the 28 sites. The injection site corresonded to the area of the 14 halanges and 3 along each metacarus, with only two for the first one. Follow-U Follow-u included eriodical outatient visits erformed at 1, 3, 6, and 12 months during which all objective and subjective evaluations were reeated. Owing to raid resonse, forefinger temerature was also determined 1 hour after treatment. Patient s satisfaction with the rocedure was assessed starting from 24 hours after treatment by asking to choose one out of five ossible resonses, as alicable: very oor, oor, good, very good, and excellent (scored 1 5). the semirone osition and mild anti-trendelenburg inclination [18]. Intraoerative monitoring included arterial and venous accesses, electrocardiogram, ulse oximetry, and forefinger temerature. Eidural anesthesia was administered through a ercutaneous three-sace intercostal block at the level of the thoracic incisions by infiltration of roivacaine 0.75%, 4 ml for each intercostal sace. These atients maintained sontaneous breathing, and sulementary oxygen was administered by means of a face mask as required. Additional injections were erformed with 10 ml of meivacaine 2% in each 5-mm ort. The camera ort was sited in the fourth intercostal sace on the midaxillary line and the oerative ort, in the third intercostal sace anterior to midaxillary line. The surgical technique usually consisted of oening the arietal leura, identifying the T2 to T3 symathetic chain, and dividing by cautery communicating branches. Subsequent dissection at the T2 level was always erformed by endoscoic scissors to avoid ossible heat injury to stellate ganglion whereas the T3 section was made with the cautery. Careful dissection of accessory branches and Kuntz nerve was erformed to revent relases. Lung reexansion was video-controlled at the end of each rocedure and enhanced by ositive ressure administered in atients through a to-and-fro valve. A temorary 10F thoracic drain was set in lace and Fig 2. Evolution of quality of life after both treatments (symathectomy, continuous line; botulinum injection, dotted line) measured as mean ercentage imrovement from the baseline by Short-form 36 hysical and mental cumulative summaries and Nottingham Health Profile (ercentage of ositive answers). Intergrou robability values are indicated when significant.

5 242 AMBROGI ET AL Ann Thorac Surg TREATMENTS OF PALMAR HYPERHIDROSIS 2009;88: Table 4. Patient Satisfaction 24 Hours and 6 and 12 Months After Symathectomy () and Toxin-A Injection () for Palmar Hyerhidrosis 24 Hours 6 Months 12 Months Degree of Satisfaction n 63 n 74 n 58 Mean score (1 5) A cost comarison in euro (1 euro 1.3 US dollar) between grous concerning devices, drugs, global time in oerating room, medical ersonnel, and hosital stay was also carried out. Statistical Evaluation Throughout, data were exressed as mean standard deviation, and osttreatment changes were indicated as the median ercentage of the baseline value. Nonarametric tests were rudentially chosen because the distribution of some variables was not normal for the secific tests. The Wilcoxon or the Mann-Whitney tests were used for aired and unaired data, resectively. Significance level was Results One-year follow-u was comlete for all atients; nevertheless 28 atients at 1 year did not fill out the roosed questionnaire. No substantial demograhic or clinical differences were found at baseline between surgery and botulinum grous (Tables 1 3). Pathologic examination confirmed the resence of symathetic ganglia in all secimens. No oerative mortality was recorded in the surgical grou. Minor ostoerative comlications were observed: ersistent intercostal ain (n 2) and slight neumothorax ( 30%; n 4), which sontaneously resolved without chest tube requirement. Mean hosital stay was days, and 31 atients were treated on an outatient basis. Comlications of botulinum injection were ersistent hand ain (n 2) and gras weakening (n 2). As reviously mentioned, crossover from one grou to another was allowed after 1 year from the treatment. Fourteen atients initially belonging to the botulinum grou underwent symathectomy; those atients were excluded from further evaluation. Objective and subjective measurements of these atients were not significantly different from the remainder of the botulinum grou (data not shown). None of the symathectomy grou underwent almar botulinum injection. Objective Evaluation Results of objective sweating assessment are summarized in Table 2. At the first month, Minor s test values were significantly imroved in both grous. On the other hand, the values at 6 months started to diverge owing to a significant deterioration in the botulinum grou ( 94% versus 63%; 0.036). This difference became more significant at 12 months ( 94% versus 30%; 0.011). A similar trend was documented with the ad glove test although the differences were earlier and more significant between grous. The increment in hand temerature was immediate in both grous without significant intergrou differences, but changes became significant after 3 months ( 30% versus 15%; 0.049) and rogressively greater. A comensatory sweating in at least one site was exerienced in 98% of the atients belonging to the surgical grou and 90% of the botulinum grou. Entity and evolution of the comensatory sweating are shown in Figure 1 and revealed a mean increment in all sites excet the face. As exected the henomenon was greater and more ersistent in the surgical grou. Subjective Evaluation Results for subjective tests are summarized in Table 3 and Figure 2 (Aendix). Hyerhidrosis quality of life imroved quickly and significantly in both grous. After 6 months changes mildly worsened in the surgical grou, whereas the decrement was greater in the botulinum injection grou ( 121% versus 85%; 0.007). Similarly, with the Dermatology Life Quality Index we documented a significant divergence starting from 6 months after treatment (Table 3). The resence of comensatory sweating had a minor influence comared with the effect of the rerise of almar sweating. No baseline differences between the two grous were found with the SF-36; however, mean values of sychosocial domains were significantly lower than that of a same-age normal oulation (Aendix). At 3 months, almost all domains of the SF-36 imroved in both symathectomy and botulinum grous. Decrement was rogressive in the botulinum grou, reaching after 1 year the baseline values. On the contrary, values of symathectomy resented only a mild deterioration, Table 5. Mean Individual Cost Comarison Between Symathectomy () and One Comlete Treatment With Toxin-A Injection () for Palmar Hyerhidrosis a Item Drugs In-room time Medical ersonnel Hosital stay Total a Currency unit Euro; 1 Euro 1.3 US dollar.

6 Ann Thorac Surg AMBROGI ET AL 2009;88: TREATMENTS OF PALMAR HYPERHIDROSIS 243 likely owing to the effect of comensatory sweating, with a significant increment of intergrou difference (Fig 2; Aendix). The same trend was documented by the Nottingham Health Profile (Fig 2; Aendix). Patient s satisfaction was initially greater in botulinum grou ( 0.03), but after 6 months it significantly reversed ( 0.04), and this difference became more evident after 1 year ( 0.001; Table 4). Cost Analysis As exected the cost analysis comaring the two grous revealed a statistically significant advantage for botulinum grou as much as fourfold (Table 5). This was mainly related to the cost of ersonnel emloyed in the sessions. Comment Palmar hyerhidrosis is a common disorder, causing social as well as sychological and occuational roblems. An effective and reliable treatment is sought by an increasing number of individuals with this disorder. Nowadays, the most effective roosed treatments are aimed at interruting innervation of sweat glands. Two main methods are referred among the others: botulinum toxin-a injection and video-assisted thoracoscoic symathectomy. The introduction of video-assisted thoracic surgery has made thoracic symathectomy a safe, less-invasive [1 7, 19 23], and relatively low-cost treatment. Rare and yet unleasant side effects are mainly reresented by comensatory hyerhidrosis. In recent years, treatment with botulinum toxin-a injection has been well established for neurologic disorders, such as bleharosasm, hemifacial sasm, torticollis, and esohageal achalasia [24]. The toxin blocks cholinergic symathetic innervation of the sweat glands by secific inhibition of acetylcholine-deendent neuroglandular transmission [8]. This chemodenervation effect has been recently used with good results in almar, axillary, and gustatory hyerhidrosis [25]. However, the theraeutic effect is limited in time, about 6 to 12 months [8 10], and today no exerience is available on the entity and frequency of side effects. Since 2001, we have erformed both treatments deending on the atient s choice. We thus have the ossibility of investigating on a nonrandomized basis the secific merits of each treatment with objective and subjective scales of evaluation. From 2002 we introduced eidural anesthesia for symathectomy with the atient awake with breathing lungs. In our exerience the oeration was feasible and results were comarable to the oeration administered under general anesthesia. Patients initially referred botulinum injection, because of the fear of a surgical rocedure with either general or eidural anesthesia. Notwithstanding, after 1 year many atients who were dissatisfied with the botulinum injection treatment reconsidered the otion of surgical rocedure with a high degree of accetance. The imact of ostoerative ain was rarely significant. In the early ostoerative eriod the ain was adequately controlled by intravenous medications. Afterward no atient resented with such a significant ain to be referred during outatient control or to worsen the score of the generic questionnaires. With objective evaluation we found that both methods were significantly effective: reduction of quantity of sweat was exerienced with Minor s iodine starch and ad glove tests. As exected, the effect of botulinum weakened after 6 months and, at the same time, the comensatory sweating decreased. On the other hand, comensatory sweating, esecially in the lumbar area, remained almost constant in the surgical grou. The subjective analysis showed a significant imrovement of all questionnaires in both grous. These effects tended to decrease starting from the third month with a more evident decrement in the botulinum arm owing to objective disaearance of the effects. In the surgical grou the decrement of the score was exlained with the onset of comensatory sweating, which affected the answers in all the questionnaires used in the study. At any result, the resence of comensatory sweating had a minor influence on quality of life comared with the effect of the rerise of almar sweating. In accordance to the existing evaluation of quality of life in literature [2, 19 23], we noted that sychosocial domains imroved more than hysical ones. This was valid for both rocedures even if the difference was more evident in the surgical arm. This trend was common to other studies [20, 23] using the SF-36 questionnaire and it is robably owing to the great social imact of this disorder involving the hands. The satisfaction score was initially suerior in the botulinum grou. This is justified by the better accetance of a medical rocedure comared with a surgical one. However, with the rogressive weakening of the toxin injection effects, the accetance became greater in the symathectomy grou. The economic consideration revealed an evident lower cost for botulinum injection, but these data should be counterbalanced with the eriodic need for reinjection. We acknowledge three major limitations in our study. First, the nonrandomized nature is a limitation. Patients had the choice between surgery or botulinum toxin, so they may be influenced by the hysician s resentation on technique and comlications. On the other hand, the atient s sychology is an imortant factor. This limit is easily justifiable by the wide difference of the two rocedures that makes a ure randomization almost unaccetable to the atient. Another limitation may be reresented by the difficulty of matching a surgically definitive theray with a medical and short-lasting method requiring eriodic reinforcements. However, evaluation of quality of life also takes into account comensatory sweating, and it can comensate this a riori bias. The study grou includes both atients who underwent surgery under general and eidural anesthesia. This might affect subjective evaluation, but not an objec-

7 244 AMBROGI ET AL Ann Thorac Surg TREATMENTS OF PALMAR HYPERHIDROSIS 2009;88: tive one, and for this reason those atients were considered in a unique grou. The inclusion of T2 ganglion for almar hyerhidrosis is related to greater comensatory sweating with T2 and worse atient satisfaction, and this is evident also from our aer. We have already started a rogram with only T3 symathectomy (section without removal), and data will be the subject of further investigations. The final limitation concerns the relatively short time of observation, restricted to 1 year, but this is related to the need of allowing a crossover from one grou to another. As a matter of fact, after 1 year 14 atients initially belonging to the botulinum grou underwent symathectomy. In conclusion, our results suggest that the definitive advantages of symathectomy are suerior to the temorary ones warranted by botulinum toxin-a injection, thus relacing the greater economic costs and discomfort caused by greater comensatory sweating. This study emhasizes the need for new rosective randomized trials comaring symathectomy with botulinum. This study has been carried out within the Research Fellowshi Program Tecnologie e Teraie Avanzate in Chirurgia awarded by the Tor Vergata University. References 1. Baumgartner FJ, Toh Y. Severe hyerhidrosis: clinical features and current thoracoscoic surgical management. Ann Thorac Surg 2003;76: De Camos JRM, Kauffman P, Werebe Ede C, et al. Quality of life, before and after thoracic symathectomy: reort on 378 oerated atients. Ann Thorac Surg 2003;76: Dumont P, Denoyer A, Robin P. Long-term results of thoracoscoic symathectomy for hyerhidrosis. Ann Thorac Surg 2004;78: Daniel TM. Thoracoscoic symathectomy. Chest Surg Clin N Am 1996;6: Gossot D, Toledo L, Fritsch S, Celerier M. Thoracoscoic symathectomy for uer limb hyerhidrosis: looking for the right oeration. Ann Thorac Surg 1997;64: Alric P, Branchereau P, Berthet JP, Leger P, Mary H, Mary- Ane C. Video-assisted thoracoscoic symathectomy for almar hyerhidrosis: results in 102 cases. Ann Vasc Surg 2002;16: Doolabh N, Horswell S, Williams M, et al. Thoracoscoic symathectomy for hyerhidrosis: indications and results. Ann Thorac Surg 2004;77: De Almeida AR, Kadunc BV, De Oliveira EM. Imroving botulinum toxin theray for almar hyerhidrosis: wrist block and technical considerations. Dermatol Surg 2001;27: Moreau MS, Cauhee C, Magues JP, Senard JM. A doubleblind, randomized, comarative study of Dysort vs. Botox in rimary almar hyerhidrosis. Br J Dermatol 2003; 149: Saadia D, Voustianouk A, Wang AK, Kaufmann H. toxin tye A in rimary almar hyerhidrosis. Randomized, single-blind, two-dose study. Neurology 2001;57: Sato KT, Richardson A, Timm DE, Sato K. One-ste iodine starch method for direct visualization of sweating. Am J Med Sci 1988;295: Kalkan MT, Aydemir EH, Karakoc Y, Korinar MA. The measurement of sweat intensity using a new technique. Tr J Med Sci 1998;28: Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)-a simle ractical measure for routine clinical use. Clin Ex Dermatol 1994;19: Ware JE, Snow KK, Kosinski M. SF-36 Health Survey. Manual and interretation guide. Lincoln, RI: Quality Metric Incororated, Hunt SM, McKenna S. The Nottingham Health Profile User s Manual, Revised Edition. Manchester: Galen Research and Consultancy, Aolone G, Mosconi P. The Italian SF-36 Health Survey: translation, validation and norming. J Clin Eidemiol 1998; 51: Bertin G, Niero M, Porchia S. L adattamento del Nottingham Health Profile al contesto italiano. In: The Euroean Grou for Quality of Life and Health Measurement. Euroean Guide to the Nottingham Health Profile. Montellier: s.a.r.1. ESCUBASE, 1992: Elia S, Guggino G, Mineo D, Vanni G, Gatti A, Mineo TC. Awake one stage bilateral thoracoscoic symathectomy for almar hyerhidrosis: a safe outatient rocedure. Eur J Cardiothorac Surg 2005;28: Kwong KF, Cooer LB, Bennett LA, Burrows W, Gamliel Z, Krasna MJ. Clinical exerience in 397 consecutive thoracoscoic symathectomies. Ann Thorac Surg 2005;80: Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscoic symathectomy for almar hyerhidrosis. Ann Thorac Surg 2005;80: Dewey TM, Herbert MA, Hill SL, Prince SL, Mack MJ. One-year follow-u after thoracoscoic symathectomy for hyerhidrosis: outcomes and consequences. Ann Thorac Surg 2006;81: Schmidt J, Bechara FG, Altmeyer P, Zirngibl H. Endoscoic thoracic symathectomy for severe hyerhidrosis: imact of restrictive denervation on comensatory sweating. Ann Thorac Surg 2006;81: Tetteh HA, Groth SG, Kast T, et al. Primary almolantar hyerhidrosis and thoracoscoic symathectomy: a new objective assessment method. Ann Thorac Surg 2009;87: Moore AP. General and clinical asects of treatment with botulinum toxin. In: Moore P, ed. Handbook of botulinum toxin treatment. Oxford: Blackwell Science, 1995: Shelley WB, Talanin NY, Shelley ED. toxin theray for almar hyerhidrosis. J Am Acad Dermatol 1998;38:

8 Aendix. Quality of Life After Symathectomy () and Toxin-A Injection () for Palmar Hyerhidrosis Evaluated by Short Form-36 (SF-36) and Nottingham Health Profile (NHP) Questionnaires a Questionnaire SF-36 Control Baseline s Hyeridrosis Versus Control 3-Month % Imrovement 6-Month % Imrovement 12-Month % Imrovement n 80 n 63 n 74 n 58 Physical functioning d 26 d d 14 c c 8 b 0.01 Role hysical Social functioning d 24 d d 15 c d Role emotional d 24 d d 18 d d 5 b Mental health d 14 c c 10 c c Bodily ain d 20 d d 14 c d 6 b General health d 32 d d 11 c d Vitality c 6 b c b Physical cumulative c 12 c c 7 b b summary Mental cumulative d 31 d d 11 c d summary NHP Mobility b b b Energy d 15 c c c Slee Pain c 6 b c c Social isolation Emotional reactions Percentage of ositive answers c 11 c b b a Baseline values are reorted as mean standard deviation. Intergrou significance: not significant. Intragrou significance with baseline values: b 0.05, c 0.01, d Ann Thorac Surg AMBROGI ET AL 2009;88: TREATMENTS OF PALMAR HYPERHIDROSIS 245