Unilateral resolution of palmar eczema and hyperhidrosis complicated by Horner's syndrome following ipsilateral endoscopic cervical sympathectomy

SIR, Endoscopic cervical sympathectomy is an effective treatment for persistent and severe hyperhidrosis but has possible complications.1–4 We describe a patient with chronic bilateral palmar hyperhidrosis and eczema, both of which resolved unilaterally after a right cervical sympathectomy. A 32‐year‐old right‐handed woman presented in 1999 to the dermatology clinic. She had had chronic bilateral hand eczema for over 20 years and bilateral palm and sole hyperhidrosis for 10 years. She had not had eczema of the feet. The hand eczema had been treated previously with various topical corticosteroids and emollients, with variable success. A right cervical sympathectomy had been performed for hyperhidrosis in November 1997, with resolution of symptoms of the right hand. Due to the complication of unilateral Horner's syndrome, sympathectomy to treat the left hand had not been performed. At presentation to our department 2 years later, she had no evidence of either eczema or hyperhidrosis of the right palm. The left hand was wet with lichenified, fissured eczema of the palm and fingers (Fig. 1). She also had right‐sided ptosis and meiosis consistent with a right Horner's syndrome. The left hand was being treated with iontophoresis using glycopyrronium bromide. Patch testing was negative. The clinical appearance of the wet left hand with lichenified, fissured eczema of the palm and fingers. Our patient had had endoscopic transthoracic sympathectomy, which is a minimally invasive procedure and is well recognized as an effective treatment for palmar and axillary hyperhidrosis.1–4 The procedure requires the ablation of the sympathetic innervation of the eccrine glands from the second to the fourth thoracic ganglia. However, complications can occur with this procedure, such as the incomplete transection of nerves secondary to variable anatomical branching of the sympathetic chain, hence leading to a 5% risk of recurrence. Other problems include compensatory hyperhidrosis affecting the back and thighs in 20% of patients. Cardiac sympathetic denervation leading to bradycardias can occur.1 Life‐threatening complications are rare, but haemothorax and pneumothorax are not uncommon. Horner's syndrome occurs in up to 40% of patients having cervical sympathectomy by conventional open surgery, and rates between 0 and 8% have been reported for those having endoscopic sympathectomy. This syndrome can be transient, or permanent as in our patient.1–3 Endoscopic sympathectomy is usually performed bilaterally. The patient's dominant hand is treated first so that maximal benefit is achieved at the earliest stage. However, the non‐dominant side is not treated if there are any complications, as in this case. Overall, a unilateral procedure is very rarely performed. In our patient there was no evidence of any compensatory hyperhidrosis or worsening of eczema on the left hand following this procedure. Interestingly, our patient had resolution of her hyperhidrosis immediately but her hand eczema also resolved within 4 weeks of the endoscopic sympathectomy. Hyperhidrosis has been associated with increased sweat gland activity. However, no definite causal link has been shown with sweating or sweat gland activity. Hyperhidrosis may contribute to the symptoms associated with hand eczema.5–6 We hypothesize the link to be present in certain groups of patients with hand eczema and hence the resolution in our patient following this procedure.