PONFOLYX
CHEIROPOMPHOLYX
 http://www.icvts.org/pdf/icvts377.pdf

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Severe pompholyx following endoscopic thoracic sympathectomy
for palmar hyperhidrosis
Hiroshi Niinai*, Masashi Kawamoto, Osafumi Yuge
Department of Anesthesiology and Critical Care Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan

Received 29 April 2004; received in revised form 17 June 2004; accepted 2 July 2004

Abstract
Endoscopic thoracic sympathectomy has become the preferred method for treating intractable palmar hyperhidrosis because of its
simplicity, though various complications have been reported. We report two patients suffered from severe palmar pompholyx-like eczema
following this procedure. One was successfully treated with topical and oral steroids, however, the other had a wavelike continuation of
eczema disturbing her daily activities. We recommend that every sympathectomy for hyperhidrosis should be performed after receiving
informed consent to the possibility of even minor complications such as acute pompholyx that could negatively affect postoperative quality
of life.

q 2004 Published by Elsevier B.V.
Keywords: Endoscopy; Sympathectomy; Hyperhidrosis; Complications of surgery

1. Introduction
Endoscopic thoracic sympathectomy (ETS), an operative
treatment for palmar hyperhidrosis, has become a common
procedure. Although ETS is very effective for reducing
palmar sweating, it is known that such complications as
pneumothorax, hemothorax, Horners syndrome, and severe
compensatory sweating should be carefully avoided [13].
Pompholyx is a form of eczema on the palms and soles, in
which edema fluid accumulates to form visible vesicles or
bullae [4]. It is a common skin feature in patients with
palmar hyperhidrosis, however, there are no reports of a
patient that developed severe pompholyx following ETS.

2. Case description

2.1. Case 1
A 34-year-old man was admitted under a diagnosis of
palmar hyperhidrosis. A physical examination and
preoperative laboratory test results were within normal
ranges. Under general anesthesia in a semi-sitting position,
following an 8-mm skin incision along the right axillary
region, a needle for insufflation was inserted through the
Th2/3 intercostal space and 1.5 l of carbon dioxide was used
to establish a pneumothorax. After a resectoscope was
inserted through the same incision into the thoracic cage, we
cut the sympathetic trunk on the surface of the Th2, Th3,
and Th4 ribs using a diathermy with coagulation mode. We
left two Kuntz fibers found on the Th3 rib. Next, on the left
side, we cut the trunk on the surface of the Th2, Th3, and
Th4 ribs in the same manner, and left two Kuntz fibers found
on the Th3 and Th4 ribs. A prophylactic antibiotics (1 g of
cefazolin sodium) was infused during the operation. The
patient recovered from general anesthesia uneventfully.
On postoperative day (POD) 1, oral antibiotics (cefaclor,
750 mg/day) and analgesics (loxoprofen sodium,
180 mg/day) were administered routinely. Sweating in the
palms and axillary regions were significantly reduced, and
the effect of the operation was considered satisfactory. On
POD 3, a form of eczema of the palms along with severe
itching was observed and diagnosed as pompholyx-like
eczema (Fig. 1), which was different clinically from drug
allergy. A steroid ointment (0.1% mometasone furoate) and
oral steroid (betamethasone, 1.5 mg/day) were prescribed
1569-9293/$ - see front matter q 2004 Published by Elsevier B.V.
doi:10.1016/j.icvts.2004.07.001
Interactive CardioVascular and Thoracic Surgery xx (xxxx) 13
www.icvts.org

2.2. Case 2
A 29-year-old woman with a diagnosis of palmar
hyperhidrosis exhibited no abnormal medical findings
preoperatively. Under the same procedures as used in
Case 1, we cut the bilateral sympathetic trunks on the
surface of the Th2 and Th3 ribs. We left three Kuntz fibers
found on the right Th3 rib, as well as two Kuntz fibers found
on the left Th2 and Th3 ribs.
Following the procedure, her palms were dry and we
considered the results to be satisfactory. On POD 3, small
vesicles with itching and pain were found on the bilateral
palms, which were diagnosed as pompholyx-like eczema.
We started treatment with a steroid ointment and oral
steroid, as in Case 1. The condition seemed to improve and
the patient was discharged from the hospital on POD 5. On
POD 9, she returned to us complaining of an attack of
itching and pain on her palms. We continued the steroid
ointment and have been following the patient for more than
2 years since the operation. She still has a wavelike
continuation of pompholyx-like eczema that was initiated
by ETS, which disturbs her daily activities.

3. Discussion
The cause of pompholyx is obscure, and its alternative
name, dyshidrotic eczema, may refer to a supposed
connection with sweat gland activity regulated by
the sympathetic nervous system. One case report of
unilateral ETS that decreased ipsilateral palmar pompholyx
implied that an alteration of sympathetic activity
affected the disease [5]. It was also reported that a
reduction in sympathetic tone associated with positive
airway pressure induced remission of pompholyx in a
patient with sleep apnea syndrome [6]. These suggest that
alterations of sympathetic tone could result in the healing
of pompholyx. It was also shown that sudomotor response
to sympathoexcitatory stimuli following ETS could be
modulated not only by the anatomical level of the
interrupted thoracic sympathetic trunk [7], but also by
the grade of interruption achieved with the procedure [8].
In the present patients, we speculated that a reduction of
sympathetic activity in the sweat glands of the palms
following ETS induced an irregular alteration in thoracic
sympathetic domination, which resulted in the formation
of pompholyx-like eczema. We do not think surgical
technique employed for these patients directly affected the
complication. It was reported that effectiveness of ETS
should not to be altered without removing nerve segment
of sympathetic trunk or cutting Kuntz fibers [9,10].
For the treatment of pompholyx, topical steroid
treatment is effective, while a course of oral steroids is
indicated for severe cases [4]. Generally, the attack
subsides spontaneously and resolution with desquamation
occurs within 23 weeks in most patients, as in Case 1.
Nevertheless, as in Case 2, recurrent attacks can cause a
wavelike continuation of symptoms that disturb daily
activities. ETS for palmar hyperhidrosis is an operation
to improve quality of life and is not a treatment for a life
threatening diseases. Therefore, full disclosure about the
procedure and its potential side effects must be given to
patients, who otherwise may regret undergoing ETS,
even though cessation of palmar sweating has been
obtained.

We recommend that every ETS for hyperhidrosis should
be performed following careful evaluation of patient
condition and after receiving informed consent to the
possibility of even minor complications such as acute
pompholyx that could negatively affect postoperative
quality of life. 



