eMedicine Specialties > Dermatology > Diseases of the Adnexa
Chromhidrosis
Updated: Dec 9, 2008
Introduction
Background
Chromhidrosis is a rare condition characterized by the secretion of colored sweat. Two glands produce sweat: eccrine and apocrine glands. Eccrine glands secrete a clear, odorless fluid that serves to regulate body temperature. Apocrine glands secrete a thick, milky sweat that, once broken down by bacteria, is the main cause of body odor.
Chromhidrosis is apocrine in origin. Although apocrine glands are found in the genital, axillary, areolar, and facial skin, chromhidrosis is reported only on the face,1 axillae,2 and breast areola.3,4 Lipofuscin pigment is responsible for the colored sweat. This pigment is produced in the apocrine gland, and its various oxidative states account for the characteristic yellow, green, blue, or black secretions observed in apocrine chromhidrosis.
In contrast, eccrine chromhidrosis is rare and occurs with ingestion of certain dyes or drugs, and pseudochromhidrosis occurs when clear eccrine sweat becomes colored on the surface of the skin as a result of extrinsic dyes, paints, or chromogenic bacteria.
Approximately 10% of people without the disease have colored sweat that is regarded as acceptable and within the normal range.
Pathophysiology
Lipofuscin is a yellowish brown pigment that is normally found in the cytoplasm of relatively nondividing cells (eg, neurons). In chromhidrosis, lipofuscins are found in a higher-than-normal concentration or a higher-than-normal state of oxidation in apocrine glands. However, why some glands experience these changes is unclear. This increased level of oxidation results in the green, blue, and even black sweat seen in chromhidrosis.
The yellow, green, and blue apocrine secretions produce a yellow fluorescence under a Wood lamp (UV 360 nm), whereas the dark brown and black apocrine secretions seldom autofluoresce. Substance P is also postulated to be an important neurotransmitter in this process.
Pseudochromhidrosis is of an extrinsic etiology in which a chemical on the surface of the skin reacts with eccrine secretions and produces the color transformation.
Frequency
United States
Incidence statistics are not available; the disease is rare.
International
Incidence statistics are not available; the disease is rare.
Race
Apocrine chromhidrosis appears to be more common in blacks than in whites, but facial chromhidrosis is described only in whites.
Sex
No sexual predilection is reported.
Age
Chromhidrosis is noted after puberty, when the apocrine glands are activated.
Clinical
History
History taking should include a detailed investigation of the patient's environment and lifestyle to exclude exogenous causes.
Quantities of apocrine sweat are less than those of eccrine sweat.
- Usually, patients report axillary staining of their undershirt and, less frequently, staining of the face or areola. Yellow is the most common color of axillary staining.
- An aura of warmth or a prickly sensation prompted by emotional or physical stimuli may precede the onset of colored sweat.
- Facial apocrine chromhidrosis is rarely described. It occurs most frequently on the cheeks and malar eminences. The secretion can often be expressed mechanically.
Physical
On careful inspection, the following signs can often be observed:
- An odorless yellow, green, blue, brown, or black and turbid secretion that can be manually expressed from apocrine-bearing skin
- Staining that is accentuated in the follicular orifices and pores
- Glistening, adherent, deeply colored flecks that appear as the secretions dry
Causes
The increased numbers of lipofuscin pigments in the secretory apocrine cells are presumed to be the cause of apocrine chromhidrosis.
Several extrinsic causes of eccrine chromhidrosis and pseudochromhidrosis include chromogenic bacteria, especially Corynebacterium species, fungi, dyes, drugs, and chemical contactants.5,6,7,8
Differential Diagnoses
Other Problems to Be Considered
Hyperbilirubinemia9,10
Pseudomonas infection
Poisoning
Dermatitis simulata
Bleeding diathesis (red sweat, hematohidrosis)
Alkaptonuria (ochronosis)11
Copper exposure (blue sweat)
Contamination from corynebacteria, paint, or clothing dye
Workup
Laboratory Studies
- No significant laboratory abnormalities have been noted with apocrine chromhidrosis.
- The following test may help to rule out other causes:
- Determination of complete blood cell counts to exclude bleeding diathesis
- Tests of urinary homogentisic acid levels to exclude alkaptonuria
- Fungal and bacteriologic cultures to exclude infectious causes of pseudochromhidrosis
Other Tests
- Wood lamp examination of colored sweat may be positive. If no sweat is produced at the time of the test, manual expression or pharmacologic stimulation with intradermal epinephrine or oxytocin (Pitocin) can be used to stimulate sweat secretion.
- Clothing fibers in contact with the secretions may also fluoresce yellow-green with standard UV microscopy.12
Histologic Findings
The apocrine glands appear normal in size and morphology, but the number of glands varies. The increased number of yellow-brown lipofuscin granules is observed in the cytoplasm of secretory cells on routine hematoxylin-eosin staining. The granules are positive on periodic acid-Schiff stains and demonstrate autofluorescence under a UV excitation wavelength of 360-395 nm. Schmorl stains may also be weakly positive.
Treatment
Medical Care
Apocrine chromhidrosis has no fully satisfactory cure or treatment. Patients can manually or pharmacologically empty the glands to achieve a symptom-free period of about 48-72 hours or until the glands replenish the pigment.
BOTOX® injections have been attempted in 3 cases with mixed results. BOTOX® is predominantly used to decrease eccrine sweat in persons with hyperhidrosis. However, recent reports demonstrated improvement of facial chromhidrosis with BOTOX® lasting 19 weeks post treatment. The mechanism by which BOTOX® suppresses apocrine chromhidrosis is unclear. BOTOX® may suppress apocrine secretion by blocking cholinergic stimulation and substance P release.13,14
A few reports have described successful treatment with capsaicin cream.15,16 Capsaicin, a crystalline alkaloid found in red peppers, is commonly used for the temporary relief of pain from rheumatoid arthritis, osteoarthritis, and neuralgias. Capsaicin depletes neurons of substance P, a neurotransmitter important in apocrine sweat production. Clinical relapse occurs when therapy is stopped.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Counterirritants
Counterirritants may be used to treat chromhidrosis.
Capsaicin (Dolorac, Zostrix)
Derived from plants of Solanaceae family. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Use 0.025% cream.
Dosing
Adult
Apply to affected area bid; not to exceed 4 applications/d
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; broken or irritated skin
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Causes significant irritation and a burning sensation during first few days of use; for external use only; avoid contact with eyes; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d.
Neuromuscular blocking agents
These agents inhibit the transmission of nerve impulses at the neuromuscular junction of skeletal muscle and/or autonomic ganglia.
Botulinum toxin A (BOTOX®)
Prevents calcium-dependent release of acetylcholine and produces a state of denervation at the neuromuscular junction and postganglionic sympathetic cholinergic nerves in the sweat glands.
Dosing
Adult
Facial chromhidrosis: 3-5 U spaced approximately 1 cm apart over affected area; total of 10-15 U into each side of face
Pediatric
Not established
Interactions
Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy; mild transient weakness and muscle weakness at toxin-treated sites may occur but resolve within 2-5 wk
Follow-up
Prognosis
- The condition persists throughout life, but slow regression of the disease is noted, as apocrine glands regress with time.
- The prognosis is good if an extrinsic cause can be identified and addressed appropriately.
Miscellaneous
Medicolegal Pitfalls
The Medscape Medical Malpractice and Legal Issues Resource Center may be of interest.
References
Barankin B, Alanen K, Ting PT, Sapijaszko MJ. Bilateral facial apocrine chromhidrosis. J Drugs Dermatol. Mar-Apr 2004;3(2):184-6. [Medline].
Mali-Gerrits MM, van de Kerkhof PC, Mier PD, Happle R. Axillary apocrine chromhidrosis. Arch Dermatol. Apr 1988;124(4):494-6. [Medline].
Griffith JR. Isolated areolar apocrine chromhidrosis. Pediatrics. Feb 2005;115(2):e239-41. [Medline].
Saff DM, Owens R, Kahn TA. Apocrine chromhidrosis involving the areolae in a 15-year-old amateur figure skater. Pediatr Dermatol. Mar 1995;12(1):48-50. [Medline].
Singal A, Thami GP. Red pseudochromhidrosis of the neck. Clin Exp Dermatol. Sep 2004;29(5):548-9. [Medline].
Thami GP, Kanwar AJ. Red facial pseudochromhidrosis. Br J Dermatol. Jun 2000;142(6):1219-20. [Medline].
Yoshida R, Kobayashi S, Amagai M, Tanaka M. Brown palm pseudochromhidrosis. Contact Dermatitis. Apr 2002;46(4):237-8. [Medline].
Hill S, Duffill M, Lamont D, Rademaker M, Yung A. Pseudochromhidrosis: blue discolouration of the head and neck. Australas J Dermatol. Nov 2007;48(4):239-41. [Medline].
Allegue F, Hermo JA, Fachal C, Alfonsín N. Localized green pigmentation in a patient with hyperbilirubinemia. J Am Acad Dermatol. Jul 1996;35(1):108-9. [Medline].
Kanzaki T, Tsuda J. Bile pigment deposition at sweat pores of patients with liver disease. J Am Acad Dermatol. Apr 1992;26(4):655-6. [Medline].
Albers SE, Brozena SJ, Glass LF, Fenske NA. Alkaptonuria and ochronosis: case report and review. J Am Acad Dermatol. Oct 1992;27(4):609-14. [Medline].
Cox NH, Popple AW, Large DM. Autofluorescence of clothing as an adjunct in the diagnosis of apocrine chromhidrosis. Arch Dermatol. Feb 1992;128(2):275-6. [Medline].
Matarasso SL. Treatment of facial chromhidrosis with botulinum toxin type A. J Am Acad Dermatol. Jan 2005;52(1):89-91. [Medline].
Wu JM, Mamelak AJ, Nussbaum R, McElgunn PS. Botulinum toxin a in the treatment of chromhidrosis. Dermatol Surg. Aug 2005;31(8 Pt 1):963-5. [Medline].
Marks JG Jr. Treatment of apocrine chromhidrosis with topical capsaicin. J Am Acad Dermatol. Aug 1989;21(2 Pt 2):418-20. [Medline].
Rumsfield JA, West DP. Topical capsaicin in dermatologic and peripheral pain disorders. DICP. Apr 1991;25(4):381-7. [Medline].
Cilliers J, de Beer C. The case of the red lingerie - chromhidrosis revisited. Dermatology. 1999;199(2):149-52. [Medline].
Daoud MS, Dicken CH. Disorders of the apocrine sweat glands. In: Fitzpatrick's Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:708-9.
Shelley WD, Hurley HJ Jr. Localized chromhidrosis: a survey. Arch Dermatol Syphilol. 1954;69:449-71.
Keywords
chromhidrosis, pseudochromhidrosis, chromidrosis, colored sweat, discolored sweat, pigmented sweat, yellow sweat, green sweat, blue sweat, black sweat, lipofuscin, Corynebacterium bacteria
Contributor Information and Disclosures
Author
June Kim, MD, Staff Physician, Department of Dermatology, University of New Mexico
June Kim, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.
Coauthor(s)
Wingfield Rehmus, MD, MPH, Co-Director of Clinical Trials, Clinical Instructor, Department of Dermatology, Stanford University Medical Center
Wingfield Rehmus, MD, MPH is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Nelly Rubeiz, MD, Consulting Staff, Department of Dermatology, American University of Beirut Medical Center; Associate Professor, Department of Dermatology, American University of Beirut, Lebanon
Nelly Rubeiz, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.
Medical Editor
Günter Burg, MD, Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland
Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association
Disclosure: Nothing to disclose.
Pharmacy Editor
Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.
Managing Editor
Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center
Disclosure: Nothing to disclose.
CME Editor
Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.
Chief Editor
Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.