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AUTHOR AND EDITOR INFORMATION

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Author: Zeina Nehme Ghorayeb, MD, Part time lecturer, University of Balamand, School of Medicine

Zeina Nehme Ghorayeb is a member of the following medical societies: Alpha Omega Alpha

Coauthor(s): Mona Matta-Muallem, MD, Associate Professor, Department of Dermatology, American University of Beirut, Lebanon

Editors: Susan M Swetter, MD, Director, Pigmented Lesion and Cutaneous Melanoma Clinic, Associate Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: trichomycosis nodosa, lepothrix

INTRODUCTION

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Background

Trichomycosis axillaris is a relatively common superficial bacterial colonization of the axillary hair shafts. Granular concretions, which are yellow, black, or red, adhere to the hair shaft and clinically characterize this condition.

Pathophysiology

Trichomycosis axillaris results from corynebacterial overgrowth on hair shafts in moist regions of the body and predominantly affects axillary hair, and to a lesser extent, pubic hair (trichomycosis pubis).

Frequency

United States

No studies have assessed the frequency of the condition in the United States.

International

In one study from the United Kingdom, trichomycosis axillaris was present in 27% of adult male students, and in the general population, 42% of male patients and 7% of female patients.

Mortality/Morbidity

Trichomycosis axillaris is a benign disease with no associated mortality or complications.

Race

No racial predilection is reported.

Sex

Both sexes may be affected; however, the disease appears to affect males more commonly, since most women shave their axillary hair.

Age

Trichomycosis axillaris can affect any age group from puberty through adulthood.


CLINICAL

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History

  • Trichomycosis axillaris typically is asymptomatic; however, patients may complain of malodorous sweat.
  • The condition may be associated with similar findings of hair concretions in the pubic area (trichomycosis pubis).

Physical

  • Concretions encircle the hair shaft, making it appear beaded or thicker. Concretions are most common on the central portion of axillary hair.
  • Concretions consist of 1- to 2-mm red, black, or yellow nodules that adhere firmly to the hair shaft. The insoluble cement substance elaborated by the bacteria adheres to the hair shaft and, occasionally, invades and destroys cuticular and cortical keratin. The yellow color is observed most commonly (Image 1) and may stain clothes yellow. Black and red are seen most commonly in tropical climates.
  • The hair shaft may become brittle and thus, more easily broken, but this is rare. Typically, since the hair shaft is not weakened, alopecia is not seen.
  • The underlying skin usually is normal, although hyperhidrosis of the affected regions is common.

Causes

Trichomycosis axillaris is caused by several species of the gram-positive diphtheroid Corynebacterium, not by a fungus as the name may imply.


DIFFERENTIALS

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Piedra

Other Problems to be Considered

Pediculosis pubis
Hair casts (usually on scalp)
Artifacts from deodorants, creams, or soaps


WORKUP

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Lab Studies

  • Potassium hydroxide preparation reveals bacteria within concretions.
  • Perform bacterial culture as needed (typically not recommended).

Imaging Studies

  • Imaging studies are not needed for the diagnosis or follow-up of patients with trichomycosis axillaris.

Histologic Findings

Corynebacterium is a gram-positive diphtheroid; it stains purple with Gram stain and appears as long, slender rods under the microscope.


TREATMENT

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Medical Care

  • The fastest method of treatment is to shave the affected hair.
  • Benzoyl peroxide (gel or wash formulations) aids in treatment and prevents recurrence.
  • Antiperspirant helps treat and prevent the condition by reducing axillary hyperhidrosis. Topical antibiotic preparations such as clindamycin or erythromycin also are effective.
  • "Drying" powders may assist treatment.


MEDICATION

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Treatment of trichomycosis axillaris can be achieved simply by shaving the affected hair. Application of a benzoyl peroxide gel or wash is effective and prevents recurrence. Antiperspirants also provide an effective means of therapy and prevention.

Drug Category: Topical skin products

Useful in the treatment of irritation caused by oxidized bacterial proteins in sebaceous follicles.

Drug NameBenzoyl peroxide (Benzac, Benoxyl, Clearasil)
DescriptionFree-radical oxygen is released upon administration and oxidizes bacterial proteins in sebaceous follicles, decreasing the number of anaerobic bacterial and irritating free fatty acids. Converted on the skin into benzoic acid, which has an antibacterial activity, as well as keratolytic and comedolytic effects.
Available in 2.5%, 5%, and 10% gels, lotions, creams, or washes.
Adult DoseApply sparingly qd; gradually increase to bid/tid prn; reduce dose, frequency or concentration if excessive dryness or peeling occurs
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity
InteractionsPotentiates adverse effects of tretinoin
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsAvoid contact with lips, eyelids, mucous membranes, and eyes; for external use only; discontinue if swelling, burning, or excessive dryness occurs

Drug Category: Antiperspirants

Interfere with normal secretions of sweat glands, drying the affected area. A variety of antiperspirants are available OTC; prescription strength topical desiccant listed below.

Drug NameAluminum chloride hexahydrate (Drysol)
DescriptionAstringent agent used in management of hyperhidrosis.
Solution of 20% aluminum chloride in ethyl alcohol.
Adult DoseApply to affected area hs; to prevent irritation, completely dry area prior to application
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity
InteractionsNone reported
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsNot for application on irritated, broken, or recently shaved skin

Drug Category: Topical antibiotics

Work by inhibiting growth of microorganisms causing trichomycosis axillaris.

Drug NameClindamycin solution (Cleocin T)
DescriptionLincosamide for treatment of serious skin and soft tissue staphylococcal infections. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Upon application to the skin, drug is converted to active component, which inhibits the microorganism.
Available as topical solution, lotion, or gel for external use. Solution contains equivalent of 10 mg/mL clindamycin.
Adult DoseApply as thin film to affected areas bid
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; history of regional enteritis, ulcerative colitis, or drug-induced colitis
InteractionsHas neuromuscular blockade activity and may potentiate effects of such drugs if administered concomitantly
PregnancyB - Usually safe but benefits must outweigh the risks.
PrecautionsProlonged use may result in overgrowth of nonsusceptible organisms (eg, fungi); discontinue use if superinfection occurs; alcohol base of solution may cause irritation of eyes and mucous membranes if accidentally applied to these areas

Drug NameErythromycin (T-Stat)
DescriptionInhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
Available as a 2% topical solution.
Adult DoseApply to affected areas bid
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity
InteractionsMay antagonize effect of clindamycin
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsMay cause irritation of eyes and mucous membranes if accidentally applied to these areas


FOLLOW-UP

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Deterrence/Prevention:

  • Benzoyl peroxide (gel or wash) use
  • Antiperspirant use
  • Shaving axillary hair

Prognosis:

  • Trichomycosis axillaris is a benign infection of the hair. Once treated, it may recur if preventive measures (eg, shaving, antibacterial soap, antiperspirants) are not taken.

Patient Education:

  • Instruct patients to keep the area dry and clean. Shaving or trimming axillary hair usually is beneficial.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Failure to make the diagnosis; however, since trichomycosis axillaris is a benign condition, missing the diagnosis or leaving the condition untreated is not associated with any mortality or morbidity


MULTIMEDIA

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Media file 1:  Yellow concretions are seen over axillary hairs.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 2:  Close-up view of axillary hairs.
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Media type:  Photo


REFERENCES

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  • Freeman RG, McBride ME, Knox JM. Pathogenesis of trichomycosis axillaris. Arch Dermatol. Jul 1969;100(1):90-5. [Medline].
  • Korting GW. Practical Dermatology of the Genital Region. Philadelphia, Pa: WB Saunders; 1980:. 59.
  • Levit F. Trichomycosis axillaris. J Am Acad Dermatol. May 1990;22(5 Pt 1):858-9. [Medline].
  • Levit F. Trichomycosis axillaris: a different view. J Am Acad Dermatol. Apr 1988;18(4 Pt 1):778-9. [Medline].
  • McBride ME, Duncan WC. Trichomycosis axillaris. Arch Dermatol. Mar 1972;105(3):459. [Medline].
  • Savin JA, Somerville A, Noble WC. The bacterial flora of trichomycosis axillaris. J Med Microbiol. May 1970;3(2):352-6. [Medline].
  • Shelley WB, Miller MA. Electron microscopy, histochemistry, and microbiology of bacterial adhesion in trichomycosis axillaris. J Am Acad Dermatol. Jun 1984;10(6):1005-14. [Medline].
  • Wilson C, Dawber R. Trichomycosis axillaris: a different view. J Am Acad Dermatol. Aug 1989;21(2 Pt 1):325-6. [Medline].

Trichomycosis Axillaris excerpt

Article Last Updated: Feb 1, 2007