Chromhidrosis: A Rare Clinical Finding

Chromhidrosis, characterized by the secretion of black-, blue-, green-, yellow-, or brown-colored sweat, is a rare medical disorder first described by James Yonge in 1709. The condition wassubsequently classified into apocrinechromhidrosis, eccrinechromhidrosis,and pseudochromhidrosis.¹

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Types of Chromhidrosis

Apocrine chromhidrosis develops in the areas where apocrine glands are present; hence, it is mainly limited to the anogenital and axillary areas, eyelids, ears, scalp, trunk, and areola. Eccrine chromhidrosis may occur almost anywhere on the body because eccrine glands are distributed with varying density throughout the skin except for the ear canal, lips, prepuce, glans penis, clitoris, and labia minora.² On the contrary, pseudochromhidrosis results when chemicals, dyes, or pigment-producing bacteria mix with eccrine sweat and form colored sweat. Infants and children are rarely affected by this disease. According to findings from a study published in the Australasian Journal of Dermatology, chromhidrosis was more commonly seen in females than in males.³ According to the International Hyperhidrosis Society, chromhidrosis is a challenging disorder to diagnose and manage, and limited information is available in the medical literature onthis condition.⁴

Clinical Presentation

The most noticeable symptom of chromhidrosis is the presence of colored sweat with an unpleasant odor.⁵ The color of the sweat can range from pale yellow to dark brown or black and may be consistent or vary depending on the type of chromhidrosis. Certain triggers, such as stress, exercise, or certain foods, may increase sweating and exacerbate the symptomsof chromhidrosis.⁶ Lipofuscin, a yellow-brown pigment often seen in the cytoplasm of nondividing cells (eg, neurons), is often responsible for colored sweat. According to findings from a recent study, apocrine chromhidrosis is characterized by oxidized lipofuscin granules in theapocrine glands.⁷

The differential diagnosis of chromhidrosis includes various other medical conditions. These conditions include hematohidrosis, a rare condition in which sweat is tinged with blood because of ruptured capillaries in the sweat glands, and hemosiderosis, a condition in which iron accumulates in tissues, leading to the production ofrust-colored sweat.⁸

The diagnosis of chromhidrosis involves a thorough medical history and physical examination. In some cases, imaging tests such as ultrasound or MRI may be ordered to assess the sweat glands and surrounding tissues.

Causes

One of the primary causes of chromhidrosis is the overproduction or accumulation of porphyrins in the sweat glands. Porphyrins are a group of organic compounds involved in the production of heme, a hemoglobin component in red blood cells. When porphyrins accumulate in the sweat glands, they can cause the sweat to take on a red, pink, or brownish hue.⁸

Another possible cause of chromhidrosis is the ingestion or topical application of certain medications or dyes.⁹ For instance, ingesting medications such as rifampicin, minocycline, and chlorpromazine have been associated with chromhidrosis. Similarly, the topical application of dyes such as Sudan black and tattoo ink has been linked tothe condition.

In rare cases, chromhidrosis may be associated with underlying medical conditions, such as hyperthyroidism, dermatitis herpetiformis, and multiple myeloma. These conditions can cause abnormal accumulation of pigments in the sweat glands, leading to chromhidrosis.¹⁰

Apocrine chromhidrosis is thought to be caused by an increase in the number of lipofuscin granules in the apocrine secretory cells. Eccrine chromhidrosis and pseudochromhidrosis can be caused by various exogenous factors, one of which is chromogenic bacteria, notably those in the Corynebacterium genus.¹¹

Management

Chromhidrosis can be distressing for the affected person and significantly affect their quality of life. The management of chromhidrosis aims to reduce the amount of pigmented sweat produced.

Topical treatment. Topical treatments, such as aluminum chloride hexahydrate solution, can be applied to the affected area to reduce sweating.¹² This treatment works by blocking the sweat glands and reducing the amount of sweat produced; however, it is not always effective. Additionally, topical application of capsaicin cream once or twice daily can also manage chromhidrosis, although it can cause a burning sensation.¹³

Oral medications. Oral medications such as anticholinergics can be used to reduce sweating. Anticholinergics work by blocking the nerve impulses that stimulate the sweat glands, thereby reducing the amount of sweat produced. However, this treatment can have adverse effects, including dry mouth and blurred vision. Additionally, discontinuing antimicrobial drugs or medication to enable the skin’s natural population of bacteria to return to balance is another potential approach to managing pseudohydrosis.¹⁴

Botulinum toxin. Botulinum toxin injections can manage chromhidrosis by blocking the nerve impulses that stimulate the sweat glands, thereby reducing the amount of pigmented sweat produced, and can have long-lasting effects.¹⁵

Surgery. Surgery is a final resort to manage chromhidrosis. Surgery involves removing the sweat glands that produce pigmented sweat. However, surgery can be risky and may result in complications such as infection and scarring.

References

1. Nervous teenager’s hands turn blue. ProQuest. Accessed February 26, 2023. https://www.proquest.com/openview/c4756372fb75a7ac4e108cc3e22afe18/1?pq-origsite=gscholar&cbl=34319

2. Wilkes D, Nagalli S.Chromhidrosis. StatPearls Publishing; 2023. Accessed February 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554395/

3. Gaffney DC, Cooper HL. Coloured sweat in two brothers: first report of familial chromhidrosis. Australas J Dermatol. 2016;57(1):e23-e25. doi:10.1111/ajd.12262

4. Chromhidrosis (colored sweat). International Hyperhidrosis Society. March 29, 1970. Accessed April 11, 2023. https://www.sweathelp.org/home/chromhidrosis.html

5. Suessman A, Srinivasan S. Chromhidrosis: an unusual cause of skin discoloration.Pediatr Emerg Care. 2021;37(12):e875-e876. doi:10.1097/pec.0000000000001790

6. Wallace C, Coulter JL, Sebes N, Seeley M. Novel presentation of pediatric complex regional pain syndrome with concurrent chromhidrosis: a case report.JBJS Case Connect. 2021;11(3):doi:10.2106/JBJS.CC.21.00194: https://pubmed.ncbi.nlm.nih.gov/35102013/

7. Bhandari S, Baral MR, Yeasmin S. Chromhidrosis.Brown Hosp Med. 2022;1(3). doi:10.56305/001c.37030

8. Heckmann M. Diseases of sweat glands.Braun-Falco’s Dermatology. Published online 2021:1-13. doi:10.1007/978-3-662-58713-3_72-1

9. Alpman N, Ak F. A case of eccrine chromhidrosis due to multivitamin use.Euras J Fam Med. 2021;10(1):33-35. doi:10.33880/ejfm.2021100106

10. Rapini RP.Practical Dermatopathology. Elsevier Health Sciences; 2021. Accessed February 26, 2023. https://books.google.com.pk/books?hl=en&lr=&id=8x8ZEAAAQBAJ&oi=fnd&pg=PP1&dq=chromhidrosis+may+be+associated+with+underlying+medical+conditions+such+as+hyperthyroidism

11. Ingvaldsen CA, Leegaard TM, Kravdal G, Mørk C. Infectious pseudochromhidrosis: a case report and literature review.Acta Derm Venereol. 2020;100(1):adv00005. doi:10.2340/00015555-3338

12. Dogan G, Aydogdu CT, Alatas ET, Hançer HS, Polat AK, Pektas SD. Familial chromhidrosis.DOD Clin Case Rep. 2018;2(1):5-8.Sahu P, Chakraborty D, Dayal S, Sachdeva M. Various color presentations of pseudochromhidrosis - a case series.Dermatol Pract Concept. 2023;13(1):e2023028. doi:10.5826/dpc.1301a28

13. Kashetsky N, Mufti A, Bagit A, Sachdeva M, Yeung J. Characteristics and treatment outcomes in chromhidrosis: a systematic review.J Am Acad Dermatol. 2021;85(4):998-1002. doi:10.1016/j.jaad.2020.08.135

14. Campanati A, Martina E, Giuliodori K, Consales V, Bobyr I, Offidani A. Botulinum toxin off-label use in dermatology: a review.Skin Appendage Disord. 2017;3(1):39-56. doi:10.1159/000452341