A surgical treatment for anxiety-triggered palmar hyperhidrosis is not unlike treating tearfulness in major depression by severing the nerves to the lacrimal glands.

Correspondence A surgical treatment for anxiety-triggered palmar hyperhidrosis is not unlike treating tearfulness in major depression by severing the nerves to the lacrimal glands SIR, The recent study of Krogstad et al. 1 in this Journal, reporting on the daily pattern of sweating and response to stress in patients with palmar hyperhidrosis, is an important contribution to the clinical literature. Patients and controls did not differ while doing 'physical activity' or 'other activity'. In contrast, in patients, but not in controls, palmar hyperhidrosis was most severe at midday during the working day (when psychological stress levels are likely to be highest). These authors conclude that their 'finding supports the idea that thermoregulatory sweating is normal in hyperhidrotic patients' but found extensive evidence that psychological stress influences patients with palmar hyperhidrosis more than controls. 1 The surgical literature (see Krogstad et al. for references) advocates sympathectomy or other surgical procedures as the first line of treatment for palmar hyperhidrosis. This is despite the frequent postsympathectomy complications, most commonly truncal compensatory hyperhidrosis, a condition which we contend is at least as uncomfortable and as socially embarrassing as palmar hyperhidrosis. Long-lasting postsurgical compensatory truncal hyperhidrosis has been reported to occur in 44–86% of patients. Palmar hyperhidrosis of clinical severity is a hallmark physical sign of many anxiety disorders, including generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and especially social phobia. 4 These are increasingly well understood and highly treatable neurobiological conditions. They are moderately heritable hard-wired fear responses, 5 and are linked to amygdalar and locus coeruleus hyper-reactivity during psycho-social stress. 6,7 Anxiety disorders are known to be much more common among women. This is consistent with the finding of Krogstad et al. that among controls sweating was reported more often by men, while among the hyperhidrosis group sweating was reported more often among women. It may be relevant that a disproportionate percentage of the published surgical studies of palmar hyperhidrosis has been conducted in Asian countries where a strong stigma exists against having any mental disorder. Because of this, many individuals from these cultures (e.g. Japan, Korea, Taiwan and Hawaii) would rather go under the knife than take psycho-tropic medications. However, all patients with palmar hyper-hidrosis should be offered and strongly encouraged to complete a full course of a psychopharmacological treatment (e.g. with a serotonin/noradrenaline reuptake inhibitor) for anxiety, the underlying cause of palmar hyperhidrosis, 4,8 before undergoing a surgical procedure. …