The Case of the Orange Sweat Chromhidrosis

1. The Case of the Orange Sweat Chromhidrosis Kristen Wyrick, Capt USAF MC David Grant Medical Center Travis AFB CA

3. IntroductionChromhidrosis A rare apocrine gland disorder Produces pigmented sweat Usually found in the axillae, face or areola More common in African Americans Unknown etiology

4. Case PresentationChief Complaint 44yo healthy female Orange stained skin, clothes and nails Symptoms for one year Concentrated across chest Asked about the use of self-tanners

6. Case PresentationChromhidrosis

7. Case PresentationChromhidrosis

8. Case PresentationMedical History PMH Br Cancer Gene-1 Positive Benign liver cysts PSH TAH/BSO (prophylactic) Meds Multivitamin Topical Testosterone cream Vaginal Estrogen cream Hormones started 6 mo after onset of symptoms

9. Case PresentationMedical History No dietary cause No occupational cause Non-smoker, Non-drinker Family History Negative for any like symptoms/ diseases

10. Case PresentationPhysical Exam Vital signs normal BMI 22 Skin Bronzing of the chest and face Nails stained orange around cuticle Intradermal Nevi No evidence of sun damage Benign exam otherwise

11. Case PresentationLab work CBC ADH Cortisol Homogentisic Acid Punch Biopsy No apocrine glands present Eccrine glands: flourescent cytoplasmic granules Rare Gram Positive Cocci

12. Case PresentationPunch biopsy site

13. Case PresentationTreatment Multivitamin Stopped Well water was tested by the county Capsaisin cream offered 10 day course of Augmentin Botulinum toxin not offered due to large affected surface area

14. DiscussionBackground First case- 1709 by Yonge Review- 1954 by Shelley and Hurley Apocrine gland Oxidised lipofuscins Most cases- black/blue pigments Limited research on etiology Not associated with systemic disorders

15. DiscussionLiterature

16. DiscussionChromhidrosis True Chromhidrosis Apocrine Gland- colored lipofuscin granules Eccrine Gland- water soluble pigments Pseudochromhidrosis Sweat becomes colored at the skin surface Ochronosis-Alkaptonuria Genetic disorder; HGAO enzyme missing Homogentisate Oxidase Enzyme, breaks down tyrosine and phenylalanine. Autorecessive Disorder Homogentisate Oxidase Enzyme, breaks down tyrosine and phenylalanine. Autorecessive Disorder

17. DiscussionDifferential Diagnosis Hyperbilirubinemia Pseudomonas infection Bleeding diathesis Alkaptonuria Poisoning Addison�s Disease Hemochromatosis

18. DiscussionChromhidrosis Associated with an aura Warmth or prickling sensation Prompted by emotional or physical excitation Diagnosis Wood�s Lamp Induce colored sweat with pharmacologic stimulation Biopsy specimen Oxidized lipofuscin granules present Pharmacologic Stimulation: Intradermal Epinephrine or PitocinPharmacologic Stimulation: Intradermal Epinephrine or Pitocin

19. DiscussionTreatment Avoid external causes when identified Treat infections Capsaicin cream Botulinum Toxin A injection Reassurance

20. DiscussionFollow-up Antibiotics did not improve her symptoms Declined request for second biopsy Continues to have stained clothing & nails Patient appreciative of the diagnosis and information on the disease

21. ConclusionChromhidrosis First Case reported Orange colored secretions Post-menopausal female Unknown incidence and etiology May consider capsaicin cream or botox Reassure patients Benign condition Spontaneous regression

22. References 1. Shelley WB, Hurley HJ. Localized chromhidrosis: a survey. Arch Dermatol. 1954;69:449-471. 2. Cilliers J, de Beer C. The Case of the Red Lingerie-Chromhidrosis Revisited. Dermatology. 1999;199:149-152. 3. Kim J. Chromhidrosis. Emedicine From WebMD. Available at: http://www.emedicine.com/derm/topic596.htm. Accessed December 15, 2006. 4. Griffith JR. Isolated Areolar Apocrine Chromhidrosis. Pediatrics. 2005 Feb;115: 239-241. 5. Mali-Gerrits MM, van de Kerkhof PC, Mier PD, Happle R. Axillary apocrine chromhidrosis. Arch Dermatol. 1988 Apr;124(4):494-496 6. Thami GP, Kanwar AJ. Red facial pseudochromhidrosis. Br J Dermatol. 2000 Jun; 142(6):1219-1220. 7. Barankin B, Alanen K, Ting PT, Sapijaszko MJ. Bilateral facial apocrine chromhidrosis. J Drugs Dermatol. 2004 Mar-Apr;3(2):184-186. 8. Saff DM, Owens R, Kahn TA. Apocrine chromhidrosis involving the areolae in a 15-year-old amateur figure skater. Pediatr Dermatol. 1995 Mar;12(1):48-50. 9. Daos MS, Dicken CH. Disorders of the apocrine sweat glands. In: Fitzpatrick�s Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003: 708-709 10. Hurley HJ, Witkowski J. Dye clearance and eccrine sweat secretion in human skin. J Invest Dermatol. 1961;36:259-272 11. Cox NH, Popple AW, Large DM. Autofluorescence of clothing as an adjunct in the diagnosis of apocrine chromhidrosis. Arch Dermatol. 1992 Feb;128(2):275-276. 12. Marks JG. Treatment of apocrine chromhidrosis with topical capsaicin. J Am Acad Dermatol. 1989:21(2):418-420. 13. Rumsfield JA, West DP. Topical Capsaicin in Dermatologic and Peripheral Pain Disorders. DICP, Annals of Pharmacotherapy. 1991;25:381-387. 14. Matarasso SL. Treatment of facial chromhidrosis with botulinum toxin type A. J Am Acad Dermatol. 2005 Jan;52(1):89-91. 15. Wu JM, Mamelak AJ, Nussbaum R, McElgunn PS. Botulinum toxin a in the treatment of chromhidrosis. Dermatol Surg. 2005 Aug;31(8 Pt 1):963-965.

23. Questions?