Adolescent hyperhidrosis: why early treatment matters

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Hyperhidrosis plagues exam takers: “even the answer sheet gets wet?”

‘Teenage hyperhidrosis’ shapes adolescents' quality of life…

Active diagnosis and early treatment matter more than waiting for spontaneous recovery

- Teenagers account for 17% of hyperhidrosis patients… onset in adolescence affects study, daily life and emotional well-being

- For exam students, stress can worsen symptoms in a vicious cycle; active treatment beats waiting for spontaneous improvement

- Options range from non-surgical care to single-port endoscopic sympathectomy depending on symptoms, with a lighter side-effect burden

Hyperhidrosis in adolescence, when activity levels are high, is often dismissed as a matter of constitution and treated as unimportant. For those living with it, however, it goes beyond mere discomfort and can markedly lower quality of life, disrupting studies and causing withdrawal from friendships.

Hyperhidrosis can be a particular burden for students preparing for the national college entrance exam. Sweaty hands make writing implements slip, soak textbooks, and dampen the OMR answer sheet, causing all sorts of trouble across the exam.

Yoon, Kangjun, President of St. Peter's Hospital and a neurosurgery specialist, explains, “Teenage hyperhidrosis patients who come to the hospital often report a heavy burden and discomfort across daily life and feel an urgent need for treatment.” He adds, “Yet most do not recognize excessive sweating as a medical condition, so quite a few come to the hospital only after a long delay.”

■ Often beginning in childhood and worsening after puberty… exam stress can aggravate symptoms

According to Health Insurance Review and Assessment Service data, about 15,000 patients visit hospitals for hyperhidrosis each year, of whom teenagers account for roughly 17% — some 2,000 patients. Teenagers also average more than two visits per person a year, higher than other age groups.

Primary hyperhidrosis, which mainly affects adolescents, occurs without any underlying disease; symptoms appear at a relatively young age and may worsen during puberty. It can occur regardless of sex, and about 25-50% of patients are known to have a family history. In general, primary hyperhidrosis is considered likely when two or more of the following apply: ▲symmetrical sweating on both sides of the body ▲excessive sweating at least once a week ▲marked interference with daily life ▲onset before the age of 25 ▲a family history ▲no sweating during sleep.

Among the primary hyperhidrosis types, axillary hyperhidrosis often begins around puberty, while palmar hyperhidrosis usually appears earlier. In the late teens, sweating patterns can become more pronounced alongside secondary sexual development, and in severe cases various reports describe emotional withdrawal or difficulty in personal relationships caused by hyperhidrosis.

This primary hyperhidrosis is even more disruptive for exam candidates, who need to concentrate. The sympathetic nerves that promote sweating respond sensitively to emotional stimuli such as tension and stress. For students, then, hyperhidrosis itself becomes a source of stress, creating a vicious cycle in which the sweating gets worse.

President Yoon, Kangjun said, “Some people simply endure it, thinking it will ease once puberty passes, but that is a misconception.” He added, “Hyperhidrosis involves a combination of factors such as family history, autonomic over-reactivity and stress, so rather than waiting for it to improve on its own, it is necessary to actively consider treatment.”

■ Consider surgery if non-surgical treatment brings little benefit… single-port endoscopic sympathectomy lightens the surgical and recovery burden↓

Among hyperhidrosis symptoms, sweating is known to be most severe on the palms and soles. Other patterns include sweating of the palms together with the armpits, or of the armpits alone. If excessive sweating in these areas disrupts daily life, it is best to visit a specialist hospital for a diagnosis.

At the hospital, a hyperhidrosis treatment plan is established after an interview and comprehensive assessment. Non-surgical options are considered first, including topical agents, drug therapy, iontophoresis and botulinum toxin injections. If symptoms are severe or these conservative treatments have little effect, surgical treatment is performed to resect the sympathetic nerve and help regulate sweat gland activity.

Endoscopic sympathectomy rarely causes serious complications and is a relatively low-burden operation. In particular, the ‘single-port endoscopic sympathectomy’ — performed endoscopically through local incisions of less than 1 cm on each side of the chest — is now the standard approach, so the burden of surgery and recovery is far lower than in the past. The procedure takes an average of under 20 minutes, the hospital stay is as short as about two days, and return to daily life is quick. Patients facing important exams such as the college entrance exam can schedule surgery five to six months in advance and allow ample recovery without disrupting their studies or daily routine.

What matters is choosing the appropriate surgical site according to the symptoms. For example, resection of the fourth thoracic sympathetic ganglion (T4) is effective for treating hyperhidrosis of the hands and armpits, while resection of the third lumbar sympathetic ganglion (L3) may be considered when hyperhidrosis of the feet is severe. Director Yoon, Kangjun, presented on the efficacy and safety of endoscopic sympathectomy for hyperhidrosis at the 59th Annual Fall Meeting of the Korean Neurosurgical Society in 2019. 

Director Yoon, Kangjun explained, “T4 thoracic and L3 lumbar sympathectomy carries a very low probability of compensatory hyperhidrosis, in which sweating recurs elsewhere on the body.” He added, “In fact, our analysis of patients who underwent this surgery at our hospital found the incidence of compensatory hyperhidrosis to be under 1%.”

One point to keep in mind, however, is the need to seek out a specialty hospital with extensive experience in hyperhidrosis surgery. Because the operation permanently divides a nerve, any adverse effect is difficult to reverse. That makes it all the more important to decide on treatment carefully, after a thorough consultation with an experienced neurosurgery specialist from the outset. In particular, if simultaneous surgery on multiple sites such as the hands, feet and armpits is being considered, the advanced technique of resecting the fourth thoracic and third lumbar sympathetic ganglia at the same time is required, so it is worth checking whether the hospital has experience with such procedures.  

In the thoracic spine, up to three complex fine nerve branches must be identified completely. Careful observation that misses not even the smallest nerve network is essential during surgery, and the risk of recurrence can only be lowered when the operation is performed by an experienced specialist with extensive surgical experience. 

President Yoon, Kangjun advised, “If hyperhidrosis is making an already sensitive adolescent withdraw, or causing real discomfort in daily life ahead of an important exam, it should not be brushed off — active diagnosis and treatment are worth seeking.” He added, “For students preparing for the national college entrance exam in particular, setting up a treatment plan before summer arrives can be a great help in the long run.”