Approach Considerations
Several therapeutic modalities are available to treat body odor. When a treatment method is chosen, it is important to consider the cultural implications and the degree of impairment in quality of life, as well as the patient's expectations and goals of treatment.
Medical treatments can include hygiene and topical antibacterial agents, drying agents, lasers, and botulinum toxin.
Surgical treatments can include surgical removal, superficial liposuction curettage, deep liposuction curettage, and upper thoracic sympathectomy.
Future directions
A novel microwave device that causes the apocrine and eccrine glands to fibrose has been used to treat both hyperhidrosis and bromhidrosis; the authors suggest that the results may be permanent and that the main adverse effect of inflammation is transient. [24]
Ultrasound technology may also be used to treat hyperhidrosis, and thus also has the potential to treat bromhidrosis. [25]
Medical Care
Hygiene and topical antibacterial agents
Conservative measures, which aim to reduce bacterial florae and maintain a dry environment, include improved hygiene and topical therapy. Hygienic measures, such as adequate washing of the axillary vault, prompt removal of sweaty clothing, and the use of topical deodorant (which covers the odor and decreases bacterial counts) are beneficial in cases of apocrine bromhidrosis. Regular shaving of axillary hair prevents the accumulation of sweat and bacteria on the hair shafts. Electrolysis might also be considered for hair removal to minimize bacterial growth.
Use of topical antibiotics, such as clindamycin, erythromycin, and benzoyl peroxide, as well as antiseptic soaps, may yield clinical benefit by limiting the growth of the contributory bacteria that decompose apocrine secretions, liberating fatty acids that have peculiar smells. Topical antibiotics, such as clindamycin and erythromycin, should only be used when other antiseptics are ineffective, because they are associated with a greater risk of bacterial resistance. Treatment of coexisting skin conditions, such as intertrigo, erythrasma, and trichomycosis axillaris, is important.
Drying agents
Measures to enhance drying and limit maceration, such as the use of antiperspirants including aluminum chloride, may improve bromhidrosis of either apocrine or eccrine origin, particularly if hyperhidrosis is a contributing factor. Antiperspirants, unlike deodorants, contain aluminum salts, which inhibit sweat production.
Iontophoresis, which disrupts sweat production, has a role in the treatment of eccrine bromhidrosis. With this method, a small electric current is passed through the skin while the affected area is placed under tap water. Typically used only for volar skin, this treatment is time intensive and should be considered only if excessive eccrine sweating contributes to the patient's body odor. Amelioration of hyperhidrosis does not reduce apocrine sweat production.
Conservative methods are ideal for mild cases. However, they do not offer a definitive cure, and results may be unsatisfactory if odor reduction is short lived and incomplete. Systemic anticholinergic agents decrease sweating, but their use can be limited by their adverse effect profile.
Lasers and botulinum toxin
For patients who desire more long-lasting treatment, a few nonsurgical options have been developed, although the data on these options are limited.
Laser
A frequency-doubled, Q-switched Nd:YAG laser (1064 nm) has been effective in axillary bromhidrosis. [26] More recently, the 1444-nm Nd:YAG laser has been used to achieve subdermal coagulation and destruction of apocrine glands, leading to effective management of bromhidrosis. [27, 28] Over 75% of patients reported satisfaction with the procedure up to 6 months afterward. [28]
Botulinum toxin
The inhibitory action of botulinum toxin A (BTX-A) to decrease sweat production by denervating eccrine sweat glands has also been applied to successfully treat axillary hyperhidrosis. [29, 30] The effect on axillary apocrine gland secretion is unknown; however, local injections of botulinum toxin A reduced axillary body odor in a small sample of healthy subjects, and 1 case of improved genital bromhidrosis after botulinum toxin A treatment is reported. [31] It is particularly effective for patients who have a strong correlation between malodor and sweating. [32] In a 2018 study of 62 adolescent patients, the use of BTX-A was rated either very good or good in 82% of patients. [33] The study used 50 U of BTX-A and provided relief of symptoms for 1 month in most patients. In some, multiple injections were required. The authors concluded that the use of BTX-A is safe and effective over long-term follow up and that patient education regarding the limitations of BTX-A and the potential for multiple injections is necessary to facilitate patient satisfaction.
Surgical Care
Surgical treatment for axillary bromhidrosis has been used in a limited fashion in the United States; however, several surgical techniques are used more widely in Asian countries, where axillary odor causes more social and psychological distress. [34]
Clearly, surgical reduction in the number of apocrine glands diminishes apocrine secretion, and because some histologic evidence to suggest overactive apocrine sweat glands contributes to bromhidrosis, surgical techniques may be the most satisfactory methods of treatment. Surgical treatment improves the long-term management of bromhidrosis, but it is associated with an increased risk of morbidity, including scarring, surgical complications, and risk of recurrence. In recent years, new minimally invasive techniques with less morbidity have been developed. These include procedures with smaller incisions, which leave the vascular plexus as well as superficial fascia intact and may lead to satisfactory results with fewer adverse effects. [35, 36]
Surgical removal
A multitude of surgical methods have been reported to date, which can be categorized into the following 3 classic types [37, 38, 39, 40, 41, 42, 43] :
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Removing only subcutaneous cellular tissue without removing skin: In some reports, axillary superficial fascia is removed in addition to the apocrine glands, with good results. [44] In minimally invasive procedures, this fascia is left intact. One novel technique used subcutaneous curettage combined with fat trimming to create a smooth surface on the axillary skin flap while removing the apocrine glands. Ninety eight percent of subjects reported good-to-excellent results, and no significant complications occurred. [45]
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Removing skin and subcutaneous cellular tissue en bloc
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Removing skin and cellular tissue en bloc, as well as removing the subcutaneous cellular tissue of the adjacent area: This is often performed by using a shaving technique on the subcutaneous tissue. [46]
Depending on the depth of the surgical injury, regeneration of gland function over a period of years may be observed. Subcutaneous tissue removal has also been combined with carbon dioxide laser to vaporize the residual apocrine glands. [47]
Superficial liposuction curettage
The superficial liposuction curettage technique is an outpatient procedure that has the advantage of being less traumatic than open surgery. Small incisions are made in the axilla, and a suction device is inserted that removes the subcutaneous tissue. This procedure offers a smaller incision, lower complication rates, and minimal postoperative care. [48, 49, 50, 51] However, its associated recurrence rate is higher than that of open surgery, leading to decreased patient satisfaction on long-term follow-up. A similar procedure, ultrasound-assisted suction aspiration, liquefies fat and sweat glands. [52, 53, 54] This treatment has recurrence rates lower than those of traditional superficial liposuction curettage and results in similarly small scars.
Deep liposuction curettage
A refined suction-curettage technique with subdermal undermining through a miniature incision, as well as introducing scissors through the same incision for further undermining of the subcutaneous tissue, leads to a higher curative rate (87.5%) versus suction-curettage alone (33%), but it resulted in complications (13.7%) such as hematoma, epidermal cyst formation, and axillary skin necrosis. [55] The authors noted that since most of the apocrine glands reside close to the subdermal vascular plexus, the complication rate is higher. Overall, because the complications were neither severe nor permanent, they reported that their patients were happy and willing to accept the higher rate of complication for greater treatment success.
Upper thoracic sympathectomy
Upper thoracic sympathectomy has also been performed for axillary bromhidrosis, and one study in Taiwan reported a satisfaction rate of 70.6%; however, this therapeutic modality has more frequently been used for axillary and palmar hyperhidrosis. [56]
Diet
Omission of certain foods may be of value if these factors can be isolated or identified as contributory factors to the bromhidrosis. Common culprits include curry spices, onions, garlic, and alcohol.
