The most persistent cases may occasionally be treated by cutting the sympathetic nerve supply.  Unfortunately, it is quite common to get unpleasant compensatory excessive sweating in other areas of the body distant to the area innervated by the sympathetic nerves which have been cut.

Surgical approaches involve cutting the sympathetic nerve supply below the level of T1 (first thoracic root).  Approaches include bilateral upper dorsal sympathectomy via the supraclavicular approach, percutaneous radiofrequency upper thoracic sympathectomy and thoracoscopic sympathicolysis.  As well as direct surgical complications, compensatory and gustatory sweating are the most commonly reported problems with this. The skin of the hands can also become uncomfortably dry. We need a bit of moisture associated with sweat production for the hands to have good grip. Very dry hands can crack and have poor grip.

In a thoracic sympathectomy where the T2/T3 sympathetic ganglia are removed, success rates of approximately 80% have been reported.  Plantar sweating may also be reduced, even though the nerve supply interrupted does not innervate the feet, presumably because of a secondary effect through decreased emotional feedback from decreased palmar hyperhidrosis.  The principal problems with surgical treatment are compensatory hyperhidrosis in other areas, as well as the surgery-related complications such as pneumothorax, Horner’s syndrome, damage to the phrenic nerve or thoracic duct.

Removal of axillary sweat glands through curettage or liposuction is also being used with success rates of approximately 90% , although this figure is debated and the operation is quite major with complications including scar formation, skin necrosis, discoloration and wound infection.