Radiofrequency Ablation for Refractory Palmar and Plantar Hyperhidrosis: A Case Report

Palmar and plantar hyperhidrosis (PH) is characterized by sweat production that far exceeds thermoregulatory needs and often has substantial effects on daily functioning, social interaction, and mental health. The condition results from sympathetically mediated overstimulation of the eccrine glands, which are innervated by unmyelinated cholinergic C-type fibers. Radiofrequency ablation (RFA) offers a minimally invasive approach to symptom control in refractory PH through heat-mediated disruption of these sympathetic fibers. Reports describing staged upper- and lower-limb RFA for combined palmar and plantar disease in a single patient remain uncommon; this is the primary reason for presenting this case.

A 21-year-old man (American Society of Anesthesiologists physical status I) presented with a 10-year history of progressive palmar and plantar hyperhidrosis that had not shown durable responses to conservative or prior interventional treatment. He used topical aluminum chloride for 2 months without meaningful benefit and subsequently underwent 2 sessions of palmar botulinum toxin injections 5 months apart, which reduced palmar sweating by an estimated 50 - 60% for approximately 2 months per session; the lower limbs were not treated. Eighteen months before the current admission, he underwent RFA of the right thoracic sympathetic chain at another center. This produced approximately 80% improvement in palmar sweating, although sweating persisted along the ulnar nerve distribution; the benefit lasted only approximately 4 months, after which symptoms recurred to baseline. During the present admission, staged RFA was performed bilaterally at L3, with different lower-limb protocols selected in advance based on the prior treatment response and the greater severity of plantar sweating on the left. Seven days later, bilateral RFA was performed at T3. At the 2-week, 1-month, and 7-month follow-up visits, the patient reported no compensatory sweating or change in cutaneous sensation. By his own assessment, overall sweating of the palms and soles was reduced by approximately 90% from baseline, with a satisfaction score of 9/10 and subjectively improved quality of life.

Staged RFA targeting both the thoracic and lumbar sympathetic chains appears to be a reasonably safe palliative option for patients with refractory combined palmar and plantar hyperhidrosis, with a more favorable complication profile than surgical sympathectomy. This case is considered reportable because it involves combined, staged treatment of both the upper and lower limbs in a single patient.