What is Bromhidrosis?

Bromhidrosis or Osmidrosis is the body odour, a usual condition in individuals. In some cases, when bromhidrosis is overpowering may become pathologic for the individuals affected. It is about a chronic condition according to which the unpleasant excessive odour comes from the skin. Bromhidrosis is related to the apocrine gland’s secretion and can significantly interfere with individual’s quality of life.

Pathophysiology

Sweat glands: types and functions

There are two different types of human sweat glands: apocrine and eccrine sweat glands.
Eccrine glands are distributed across the skin surface of the human body where they are engaged in thermoregulation mechanisms through the sweat production.
Apocrine glands are distributed over the armpits, breast and the area between genitals and anus. They have no role on the thermoregulatory function; however they serve as smell glands. Their secretion is an oily fluid in small amount which on reaching the skin surface produces a characteristic odour due to its bacterial decomposition. Studies have shown that apocrine glands are numerous and bigger in those with bromhidrosis.

Apocrine odour

Apocrine bromhidrosis is different than the eccrine bromhidrosis; it is far most common form of bromhidrosis which is caused by several factors. Due to the bacterial decomposition of the apocrine secretion, short-chain fatty acids and ammonia are yielded on the skin surface given off characteristic strong smell.

Eccrine Odour

Eccrine secretion is mainly odourless, however sometimes it assumes an annoying smell causing the eccrine bromhidrosis. As keratin in the skin is softened by the sweat (eccrine glands), bacteria degrade keratin yielding an unpleasant odour.

Also, eccrine bromhidrosis may be caused by the consumption of food such as onion, garlic and curry, or by the ingestion of alcohol, toxins and drugs. Endogenous or metabolic reasons may also result eccrine odour.

It is not yet clear the role of excessive sweat related to the eccrine gland’s secretion (hyperhidrosis) in the pathogenesis of sweat odour. Hyperhidrosis is more likely to trigger the apocrine sweat and promote bromhidrosis by creating a wet environment that encourages bacteria to overgrow. However, the heavy eccrine sweat results a decrease in bad smell as it eliminates the annoying apocrine sweat.

Epidemiology

Apocrine odour is associated with a positive family history of excessive sweat in some ethnic groups, such as in Asians. It occurs mainly after puberty and is more common in men as they have a greater number of apocrine glands in comparison with women.
Unlike eccrine odour, apocrine odour is more common in people with dark skin. Eccrine odour occurs in people of all races.

Patient hygiene

Patients with sweat odour problem have to follow an appropriate way of hygiene using antiperspirants and antibacterial soaps. They also should know and accept that a bad smell arises from sweaty pits on their clothes.

Patient history

Axillary odour is the most common body odour. However many people present unpleasant odour from some other regions of the body (genital or plantar bromhidrosis).

Physical examination

As a functional and metabolic disease, bromhidrosis is not typically related to any anatomic disorder. People with axillary odour usually appear normal skin, except when some skin conditions happen, such as axillaris trichomycosis (visible concretions on the hairs in the armpit) or erythrasma.

Causes

Excessive secretion from either theapocrine or eccrine glands that become 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
  • colonization with other bacteria

Eccrine bromhidrosis may rarely be caused by metabolic disorders, primary disturbances in amino acid metabolism, sweaty feet syndrome, the odour of cat syndrome 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.

 Diagnostic considerations

  • Liver failure (fetor hepaticus), which has a characteristic rotten-eggs odour in the breath and urine Renal failure, which is associated with urinelike odour.
  • Schizophrenia, which may be associated with a characteristic unpleasant body odour.
  • Olfactory hallucinations, in which the patient’s perception of body odour may be represented, sign of neurologic disease or organic brain lesions.
  • Body dysmorphic disorder.
  • Fish odour syndrome.
  • Olfactory reference syndrome, which is characterized by a false belief of having significant and offensive body odour.

Lab studies

The clinical tool required for diagnosis is the olfactory perception. Spectroscopy or chromatography may identify substances produced by the odour. However, the results of both examinations cannot help in differentiating odour caused by apocrine sweat and normal odour. For this reason, the starch-iodine test can be applied on the regions where excessive sweating exists, but the associated malodor cannot be characterized.

Histologic findings

Typically, studies have shown that in case of apocrine bromhidrosis there are no histologic abnormalities in the sweat glands or skin of patients; however, some other studies indicate that the apocrine glands are increased in number and size in the skin of patients with bromhidrosis condition.

Treatment and management

Body odour treatment is available through a range of several therapeutic methods. Only miraDry provides a non-invasive treatment that offers a lasting solution for axillary hyperhidrosis and bromhidrosis. It should be understood that various surgical methods provide lasting results; however, these methods are associated with an increased risk of morbidity and risk of recurrence. A treatment must be chosen according to the patient’s expectations, cultural implications and the impact in quality of life.

 

  1. Non-invasive miraDry treatment – Long-lasting results

MiraDry is the only non-invasive treatment to permanently eliminate the axillary hyperhidrosis and bromhidrosis. The treatment is completed in one single session that takes about one hour. The procedure is painless, easy and the results are immediate and long-lasting.
The miraDry treatment uses the most advanced microwave technology applied in various fields of medicine over the past three decades and is now applied in dermatology to effectively eliminate the axillary hyperhidrosis and bromhidrosis. Miramar Labs in U.S.A. is the first company to gain FDA clearance to use microwave energy to combat excessive underarm sweating and odour.
MiraDry uses a non-invasive handheld device to deliver precisely controlled electromagnetic energy beneath the underarm skin to the specific area where eccrine and apocrine sweat glands are located, resulting in thermolysis of the sweat glands. While the sweat glands are being eliminated through electromagnetic technology, the top layers of the skin are simultaneously cooled and protected. Microwaves lie in the electromagnetic spectrum between infrared waves (such as LASER) and radio waves (RF devices).
With minimal to no downtime, miraDry is indicated for primary axillary hyperhidrosis and bromhidrosis treatment in adults 18 and older, as well, as in patients under the age of 18 with the consent of a legal guardian.

 

  1. Hygiene and topical antibacterial agents – temporary solution

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 odour 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 and erythromycin and 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 should only be used when other antiseptics are ineffective because they are associated with a greater risk of bacterial resistance.

 

  1. Drying agents – temporary solution

Measures to enhance drying and limit maceration, such as the use of antiperspirants including aluminium chloride, may improve bromhidrosis of either apocrine or eccrine origin, particularly if hyperhidrosis is a contributing factor. Antiperspirants, unlike deodorants, contain aluminium 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 odour. 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 odour reduction is short lived and incomplete. Systemic agents decrease sweating, but their use can be limited by their adverse effect profile.

 

  1. LASER και btx – temporary solution

For patients who desire more long-lasting treatment, a few nonsurgical options have been developed, although the data on these options are limited. A frequency-doubled, Q-switched Nd:YAG laser (1064 nm) has been effective in axillary bromhidrosis. 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. Over 75% of patients reported satisfaction with the procedure up to 6 months afterwards.
The inhibitory action of botulinum toxin A (btx) 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 odour in a small number of healthy subjects, and 1 case of improved genital bromhidrosis after botulinum toxin A treatment is reported.

 

  1. Surgical axillary techniques – Long-lasting results

Surgical techniques are used mainly in Asia, where underarm bromidhrosis has intense psychological and social effects. These techniques improve the management of the axillary odour in long term as diminish the apocrine secretion; however, they are associated with procedure complications, scarring and possibility of recurrence. Last years, some new techniques, minimally invasive, have been developed leading to good results with a few number of adverse effects.

 

  1. Removal of the subcutaneous tissue – Long-lasting results

The surgical removal methods are divided into three types:

  • Removal of the subcutaneous tissue without skin removal. The thin layer of the fatty connective tissue (superficial fascia) in the armpit is removed together with the apocrine glands with efficiency.
  • Removal of the subcutaneous tissue together with the skin.
  • Removal of the subcutaneous tissue, of the skin and also of the subcutaneous tissue of the neighboring area by shaving the subcutaneous tissue.

 

  1. Superficial liposuction – Long-lasting results

It is an outpatient method, less traumatic than the open surgery. According to this procedure, small incisions are made through the skin in the area of the armpit while a device is inserted to eliminate the hypodermis (subcutaneous tissue). Although the method is less invasive than the open surgery and offers low complication and minimal recovery, its recurrence rate is high, decreasing the patient satisfaction.