| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Dermatology > DISEASES OF THE ADNEXA
Bromhidrosis
Article Last Updated: Feb 16, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Wingfield Rehmus, MD, MPH, Co-Director of Clinical Trials, Clinical Instructor, Department of Dermatology, Stanford University Medical Center
Wingfield Rehmus is a member of the following medical societies: American Academy of Dermatology
Coauthor(s):
Katherine Brown, BA, Stanford University School of Medicine;
Nelly Rubeiz, MD, Consulting Staff, Department of Dermatology, American University of Beirut Medical Center; Associate Professor, Department of Dermatology, American University of Beirut, Lebanon
Editors: Timothy McCalmont, MD, Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
Author and Editor Disclosure
Synonyms and related keywords:
osmidrosis, bromidrosis, fetid perspiration, foul-smelling perspiration, body odor, BO, apocrine bromidrosis, eccrine bromidrosis, 3M2H, E-3M2H, ASOB1, ASOB2, hyperhidrosis, offensive smell
Background
Bromhidrosis, also known as bromidrosis or body odor is a common phenomenon in postpubertal individuals. In rare cases, bromhidrosis may become pathologic if it is particularly overpowering or if it significantly interferes with the lives of the affected individuals. Bromhidrosis is a chronic condition in which excessive odor, usually an unpleasant one, emanates from the skin. This condition, determined largely by apocrine gland secretion, can substantially impair a person's quality of life.
Pathophysiology
Human secretory glands are primarily divided into 2 types: apocrine and eccrine. Eccrine glands are distributed over the entire skin surface, where they are involved in thermoregulation by means of sweat production. In contrast, apocrine glands have a limited distribution involving the axilla, genital skin, and breasts. Apocrine elements are also found in the periorbital and periauricular areas. Apocrine glands have no thermoregulatory role but are responsible for characteristic pheromonal odors.
Apocrine bromhidrosis is the most prevalent form and should be differentiated from the less common eccrine bromhidrosis. Several factors contribute to the pathogenesis of apocrine bromhidrosis. Bacterial decomposition of apocrine secretion yields ammonia and short-chain fatty acids, with their characteristic strong odors. The most abundant of these acids is (E)-3-methyl-2-hexanoic acid (E-3M2H), which is brought to the skin surface bound by 2 apocrine secretion odor-binding proteins (ASOB1 and ASOB2). One of these binding proteins, ASOB2, has been identified as apolipoprotein D (apoD), a known member of the lipocalin family of carrier proteins.
Axillary bacterial florae have been shown to produce the distinctive axillary odor by transforming nonodiferous precursors in sweat to more odiferous volatile acids. The most common of these are E-3M2H and (RS)-3-hydroxy-3-methlyhexanoic acid (HMHA), which are released through the action of a specific zinc-dependent N-alpha-acyl-glutamine aminoacylase (N-AGA) from Corynebacterium species. This aminoacylase has recently been demonstrated to also release other odiferous acids from glutamine conjugates in sweat, which may be the basis of individual body odor.
In certain circumstances, eccrine secretion, which is typically odorless, assumes an offensive aroma and causes eccrine bromhidrosis. When eccrine sweat softens keratin, bacterial degradation of the keratin yields a foul smell. Ingestion of some foods, including garlic, onion, curry, alcohol, certain drugs (eg, penicillin, bromides), and toxins may cause eccrine bromhidrosis. Last, eccrine bromhidrosis may result from underlying metabolic or endogenous causes.
The role of excessive eccrine secretion, or hyperhidrosis, in the pathogenesis of bromhidrosis is unclear. Hyperhidrosis may promote the spread of apocrine sweat and contribute further to bromhidrosis by creating a moist environment, one ripe for bacterial overgrowth. Conversely, eccrine hyperhidrosis may cause a decrease in odor because the eccrine sweat flushes away the more odiferous apocrine sweat.
Frequency
United States
The incidence of bromhidrosis is unclear, but the diagnosis is generally considered rare.
International
The diagnosis is more common in many Asian countries, where even minimal body odor is associated with personal distress, than elsewhere. Although the incidence is not reported, the social stigma of body odor leads more patients to seek treatment in these countries than in other countries.
Mortality/Morbidity
No morbid sequelae are known.
Race
- Apocrine bromhidrosis is believed to be more common in patients in dark-skinned ethnic groups than in others.
- In Asian patients, apocrine bromhidrosis may be associated with a positive family history.
- Eccrine bromhidrosis occurs in all races.
Sex
Bromhidrosis exhibits a male predominance, which may be a reflection of greater apocrine gland activity in men than in women.
Age
- Axillary bromhidrosis depends on apocrine function and therefore manifests exclusively after puberty. It occurs only rarely in the elderly population.
- In contrast, eccrine bromhidrosis is more common than apocrine bromhidrosis during childhood, but it may occur at any age.
History
Patients present with particularly offensive body odor that most commonly originates from the axillary region. However, the condition may also occur as genital or plantar bromhidrosis. The odor has been described as pungent, rancid, musty, or sour in character.
Physical
Bromhidrosis is a metabolic and functional disease not typically associated with any anatomic disturbance. Therefore, results of physical examination of patients with axillary bromhidrosis are usually unremarkable. The skin appears normal, except when bromhidrosis is associated with concomitant skin conditions such as erythrasma, in which case a sharply marginated erythematous macular rash is seen, or trichomycosis axillaris, in which case concretions are visible on the hairs in the affected area.
In contrast, individuals with eccrine bromhidrosis caused by bacterial degradation of keratin may have maceration and a thick mat of moist keratin on examination. This finding is most common on the plantar and intertriginous surfaces.
Several case reports have described a nasal foreign body as a cause of generalized bromhidrosis. Therefore, examiners should conduct thorough visualization and palpation of nasal passages in pediatric patients.
Causes
- Excessive secretion from either apocrine or eccrine glands that becomes malodorous on bacterial breakdown is the predominant cause of bromhidrosis.
- Inadequate hygiene and medical or dermatologic conditions associated with hyperhidrosis or overgrowth of bacteria may further contribute to its development. Examples include the following:
- Obesity
- Diabetes mellitus
- Intertrigo
- Trichomycosis axillaris
- Erythrasma
- Nasal foreign body is a reported cause of generalized bromhidrosis in the pediatric population.
- Eccrine bromhidrosis may rarely be caused by metabolic disorders, primarily disturbances in amino acid metabolism (which include phenylketonuria, trimethylaminuria [fish odor syndrome]), sweaty feet syndrome, odor of cat syndrome, isovaleric academia, and hypermethioninemia.
- Ingestion of certain foods, drugs, or toxic materials may cause eccrine bromhidrosis.
- Older medical textbooks report that offensive smells were characteristic of diseases like gout, scurvy, or typhoid, secondary to metabolite excretion in sweat.
Erythrasma
Trichomycosis Axillaris
Other Problems to be Considered
Liver failure (fetor hepaticus), which has a characteristic rotten-eggs odor in the breath and urine
Renal failure, which is associated with urinelike odor
Schizophrenia, which may be associated with a characteristic unpleasant body odor
Olfactory hallucinations, in which the patient's perception of body odor may be presenting sign of neurologic disease or organic brain lesions
Body dysmorphic disorder
Trimethylaminuria (fish odor syndrome)
Lab Studies
- Typically, the olfactory perception of the diagnostician is the only clinical tool required for diagnosis.
- Chromatography or spectroscopy may help identify odor-producing chemicals; however, the specific identification of odoriferous molecules is largely of academic interest and lacks diagnostic or therapeutic importance.
- In addition, results of chromatography or spectroscopy do not help in differentiating normal odor from odor caused by bromhidrosis.
- If concomitant erythrasma, a chronic bacterial infection of Corynebacterium minutissimum is suspected, the skin has a characteristic coral-red fluorescence under Wood lamp examination, and a potassium hydroxide preparation is negative for hyphae.
- Potassium hydroxide preparation shows bacteria within concretions from axillary hair in cases of trichomycosis axillaris.
- If an underlying metabolic disorder is suspected as a cause of odor, specific testing of urine or sweat may be indicated to detect the aberrant amino acid product.
Imaging Studies
- No imaging studies are indicated for the evaluation of bromhidrosis.
Other Tests
- Skin biopsy is rarely indicated.
- However, skin biopsy may be used to evaluate apocrine glands if surgical treatment options are being considered.
Histologic Findings
Evidence about histologic findings in patients with bromhidrosis is conflicting. Although some research indicates that no histologic abnormalities are seen in the skin or glands of patients with apocrine bromhidrosis when compared with control subjects, a few studies have shown that the number and the size of apocrine glands is increased in bromhidrosis skin. This finding suggests increased apocrine sweating as a possible cause of this bothersome condition.
Medical Care
Several therapeutic modalities exist 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.
Conservative measures, which aim to reduce bacterial flora 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 and antiseptic soaps limit the growth of contributory bacteria and may yield clinical benefit. Treatment of coexisting skin conditions, such as intertrigo, erythrasma, and trichomycosis axillaris is important.
Measures to enhance drying and limit maceration, such as the use of antiperspirants or 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 they are not commonly used because of their significant adverse effect profile.
For patients who desire more permanent treatment, a few nonsurgical options have been developed in recent years, though the data about these options are limited. A frequency-doubled, Q-switched Nd:YAG laser is effective in axillary bromhidrosis. The inhibitory action of botulinum toxin A to decrease sweat production by denervating eccrine sweat glands has also been applied to successfully treat axillary hyperhidrosis. 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. Although this method has not been widely tested in treating body odor, it may represent a future therapy for significant bromhidrosis.
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.
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 techniques with less morbidity have been developed, though often at the cost of less effective results.
- Surgical removal of the apocrine glands is accomplished by means of en bloc excision of the axillary skin and subcutaneous tissue or excision of only the subcutaneous tissue. This is often done by using a shaving technique on the subcutaneous tissue. 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.
- The superficial liposuction curettage technique has the advantage of being less traumatic than open surgery. It also offers a smaller incision, a lower complication rate, and minimal needs for postoperative care. However, its 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 gland. This treatment has recurrence rates lower than those of traditional superficial liposuction curettage and results in similar small scars.
Diet
Omission of certain foods may be of value if these factors can be isolated or identified as contributory factors. Common culprits include curry spices, onions, garlic, and alcohol.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Antibacterial agents
Bacteria have been implicated in the pathogenesis of bromhidrosis; the organisms decompose apocrine secretions, liberating fatty acids that have peculiar smells.
| Drug Name | Clindamycin (Cleocin, Clindagel) |
|---|
| Description | Inhibits bacterial growth by binding to 50S ribosomal subunit and blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis. |
|---|
| Adult Dose | Apply to affected area once or twice daily for 4-6 weeks. |
|---|
| Pediatric Dose | Administer as in adults. |
|---|
| Contraindications | Documented hypersensitivity, history of pseudomembranous colitis |
|---|
| Interactions | Concomitant topical acne therapy may have cumulative irritant effect; antagonism has occurred when coadministered with erythromycin. |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Drying and irritation are common adverse effects; bloody diarrhea and pseudomembranous colitis reported (rare); prolonged use may cause overgrowth of nonsusceptible organisms |
|---|
| Drug Name | Erythromycin (Erythro-Statin 2%, Akne-mycin, Theramycin Z) |
|---|
| Description | Macrolide antimicrobial that inhibits bacterial growth by binding reversibly to 50S ribosomal subunit and blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis. Use 2-4% solution. |
|---|
| Adult Dose | Apply to affected area twice daily for 4-6 wk. |
|---|
| Pediatric Dose | Administer as in adults. |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Concomitant topical acne therapy may have cumulative irritant effect; antagonism has occurred when coadministered with clindamycin. |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Discontinue if irritation or sensitivity occurs. |
|---|
Patient Education
- Patients should be encouraged to maintain an appropriate level of hygiene with the use of antibacterial soaps and antiperspirants.
- Patients also should be aware of the odor that may arise from dried sweat on clothes.
Medical/Legal Pitfalls
- Failure to recognize systemic diseases (eg, fish odor syndrome) that contribute to the development of offensive odor could serve as the basis for a claim of delay in diagnosis if body odor was the chief presenting sign.
- Generally, the legal risk in this arena is low.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Shereen Timani MD, to the development and writing of this article.
- Bang YH, Kim JH, Paik SW, et al. Histopathology of apocrine bromhidrosis. Plast Reconstr Surg. Aug 1996;98(2):288-92. [Medline].
- Battal NM, Hata Y. A classic surgical method for the treatment of axillary osmidrosis. Plast Reconstr Surg. Aug 1997;100(2):550-1. [Medline].
- Born G. Surgical treatment of axillary osmidrosis. Plast Reconstr Surg. Dec 1995;96(7):1753. [Medline].
- Chung S, Yoo WM, Park YG, et al. Ultrasonic surgical aspiration with endoscopic confirmation for osmidrosis. Br J Plast Surg. Apr 2000;53(3):212-4. [Medline].
- Eun HC, Kim KH, Lee YS. Unusual body odour due to a nasal foreign body in a child. J Dermatol. Oct 1984;11(5):501-3. [Medline].
- Fan YM, Wu ZH, Li SF, Chen QX. Axillary osmidrosis treated by partial removal of the skin and subcutaneous tissue en bloc and apocrine gland subcision. Int J Dermatol. Nov 2001;40(11):714-6. [Medline].
- Goffin V, Arrese JE, Pierard-Franchimont C, Pierard GE. [Do you have a good nose? Small lexicon of bromhidroses and other body odors]. Rev Med Liege. Dec 1999;54(12):931-4. [Medline].
- Golding IM. An unusual cause of bromidrosis. Pediatrics. Nov 1965;36(5):791-2. [Medline].
- Grazer FM. A noninvasive surgical treatment of axillary hyperhidrosis. Clin Dermatol. Jul-Sep 1992;10(3):357-64. [Medline].
- Guillet G, Zampetti A, Aballain-Colloc ML. Correlation between bacterial population and axillary and plantar bromidrosis: study of 30 patients. Eur J Dermatol. Jan-Feb 2000;10(1):41-2. [Medline].
- Heckmann M, Teichmann B, Pause BM, Plewig G. Amelioration of body odor after intracutaneous axillary injection of botulinum toxin A. Arch Dermatol. Jan 2003;139(1):57-9. [Medline].
- Hong JP, Shin HW, Yoo SC, et al. Ultrasound-assisted lipoplasty treatment for axillary bromidrosis: clinical experience of 375 cases. Plast Reconstr Surg. Apr 1 2004;113(4):1264-9. [Medline].
- Inaba M, Anthony J, Ezaki T, Mackinstry C. Regeneration of axillary hair and related phenomena after removal of deep dermal and subcutaneous tissue by a special "shaving" technique. J Dermatol Surg Oncol. Dec 1978;4(12):921-5. [Medline].
- Katz HP, Katz JR, Bernstein M, Marcin J. Unusual presentation of nasal foreign bodies in children. JAMA. Apr 6 1979;241(14):1496. [Medline].
- Kim IH, Seo SL, Oh CH. Minimally invasive surgery for axillary osmidrosis: combined operation with CO2 laser and subcutaneous tissue remover. Dermatol Surg. Nov 1999;25(11):875-9. [Medline].
- Kunachak S, Wongwaisayawan S, Leelaudomlipi P. Noninvasive treatment of bromidrosis by frequency-doubled Q-switched Nd:YAG laser. Aesthetic Plast Surg. May-Jun 2000;24(3):198-201. [Medline].
- Lee JB, Kim BS, Kim MB, et al. A case of foul genital odor treated with botulinum toxin A. Dermatol Surg. Sep 2004;30(9):1233-5. [Medline].
- Leyden JJ, McGinley KJ, Holzle E, et al. The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol. Nov 1981;77(5):413-6. [Medline].
- Lillis PJ, Coleman WP. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin. Jul 1990;8(3):479-82. [Medline].
- Lockman DS. Olfactory diagnosis. Cutis. Jun 1981;27(6):645-7. [Medline].
- Lucky AW. Acquired bromhidrosis in an 8-year-old boy secondary to a nasal foreign body. Arch Dermatol. Jan 1991;127(1):129. [Medline].
- Moriarty RA. Nasal foreign body presenting as an unusual odor. Am J Dis Child. Jan 1978;132(1):97-8. [Medline].
- Natsch A, Derrer S, Flachsmann F, Schmid J. A broad diversity of volatile carboxylic acids, released by a bacterial aminoacylase from axilla secretions, as candidate molecules for the determination of human-body odor type. Chem Biodivers. Jan 2006;3(1):1-20. [Medline].
- Ou LF, Yan RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg. Oct 1998;102(5):1479-85. [Medline].
- Park DH, Kim TM, Han DG, Ahn KY. A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures. Ann Plast Surg. Nov 1998;41(5):488-97. [Medline].
- Park JH, Cha SH, Park SD. Carbon dioxide laser treatment vs subcutaneous resection of axillary osmidrosis. Dermatol Surg. Apr 1997;23(4):247-51. [Medline].
- Park S. Very superficial ultrasound-assisted lipoplasty for the treatment of axillary osmidrosis. Aesthetic Plast Surg. Jul-Aug 2000;24(4):275-9. [Medline].
- Park YJ, Shin MS. What is the best method for treating osmidrosis?. Ann Plast Surg. Sep 2001;47(3):303-9. [Medline].
- Perng CK, Yeh FL, Ma H, et al. Is the treatment of axillary osmidrosis with liposuction better than open surgery?. Plast Reconstr Surg. Jul 2004;114(1):93-7. [Medline].
- Sato T, Sonoda T, Itami S, Takayasu S. Predominance of type I 5alpha-reductase in apocrine sweat glands of patients with excessive or abnormal odour derived from apocrine sweat (osmidrosis). Br J Dermatol. Nov 1998;139(5):806-10. [Medline].
- Senol M, Fireman P. Body odor in dermatologic diagnosis. Cutis. Feb 1999;63(2):107-11. [Medline].
- Spielman AI, Sunavala G, Harmony JA, et al. Identification and immunohistochemical localization of protein precursors to human axillary odors in apocrine glands and secretions. Arch Dermatol. Jul 1998;134(7):813-8. [Medline].
- Swartling C, Naver H, Pihl-Lundin I, et al. Sweat gland morphology and periglandular innervation in essential palmar hyperhidrosis before and after treatment with intradermal botulinum toxin. J Am Acad Dermatol. Nov 2004;51(5):739-45. [Medline].
- Tung TC. Endoscopic shaver with liposuction for treatment of axillary osmidrosis. Ann Plast Surg. Apr 2001;46(4):400-4. [Medline].
- Wang HJ, Cheng TY, Chen TM. Surgical management of axillary bromidrosis--a modified skoog procedure by an axillary bipedicle flap approach. Plast Reconstr Surg. Sep 1996;98(3):524-9. [Medline].
- Wu WH, Ma S, Lin JT, et al. Surgical treatment of axillary osmidrosis: an analysis of 343 cases. Plast Reconstr Surg. Aug 1994;94(2):288-94. [Medline].
- Zeng C, Spielman AI, Vowels BR, et al. A human axillary odorant is carried by apolipoprotein D. Proc Natl Acad Sci U S A. Jun 25 1996;93(13):6626-30. [Medline].
Bromhidrosis excerpt Article Last Updated: Feb 16, 2007
|
