The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limb, in May 2014.


Primary hyperhidrosis is characterised by excessive, bilateral sweating, most commonly affecting the axillae, palms, feet and face. It typically begins during childhood or adolescence, but can occur at any age and runs a chronic course. In a few people, symptoms can spontaneously improve over time. Excessive sweating can have a profound effect on quality of life, interfering with daily activities, and causing anxiety and embarrassment.

First-line management of primary hyperhidrosis includes lifestyle measures, such as avoiding known triggers, avoiding tight clothing and using antiperspirants (including aluminium chloride hexahydrate). Iontophoresis involves immersing the sites of hyperhidrosis in warm water (or a wet contact pad may be applied) through which a weak electric current is passed. It is suitable for the hands, feet, and less easily, the axillae. Oral medications used to treat hyperhidrosis include anticholinergics and antimuscarinics, beta-blockers, antihypertensives and anxiolytics. Another treatment option is botulinum-toxin A, delivered by multiple intradermal injections to the affected areas. If the hyperhidrosis fails to respond to conservative treatment, surgical options include local sweat-gland excision by subcutaneous curettage or tumescent liposuction, and sympathectomy. Sympathectomy involves dividing appropriate parts of the sympathetic chain beside the vertebral column: this removes the sympathetic drive that promotes sweating.

Coding and clinical classification codes for this guidance

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)