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#2 Derm > 20 - Disorders of Sweat Glands > Flashcards

20 - Disorders of Sweat Glands Flashcards

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1
Q

Sweat glands

A
  • Body has 2-5 million sweat glands

- Apocrine and eccrine

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2
Q

Apocrine sweat glands

A
  • Inactive until puberty, produce thick fluid
  • Secretions come in contact with bacteria on the skin and produce characteristic “body odor”
  • Found in axillary and genital areas
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3
Q

Eccrine sweat glands

A
  • Approximately 3 million eccrine sweat glands, secrete a clear, odorless fluid
  • Aid in regulating body temperature
  • Not found on mucous membranes or nail beds
  • Areas of concentration:facial, palms, plantar feet, and axillae
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4
Q

Eccrine gland anatomy

A
  1. Coiled secretory portion
  2. Straight dermal duct
  3. Coiled dermal duct
  4. Coiled intraepidermal duct
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5
Q

Eccrine gland duct system

A

Dermal duct
o Function is to modify secretion with resorption of water

Coiled duct
o Found deep in reticular dermis or subcutaneous-dermal junction
o Opens into duct system through dermal layer
o Enters epidermis between the papillae
o Corkscrew channel extends to outer layer of epidermis and terminates as a trumpet-shaped pore

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6
Q

Stimulation of eccrine glands

A
  • Glands on forehead, palms and soles respond to psychogenic stimulation
  • Glands on hairy surfaces respond to thermal stimulation
  • Thermal sweating – dependent on intact hypothalamus
  • Psychogenic sweating – limbic system control
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7
Q

Role of hypothalamus in sweating

A
  • Can be triggered by exercise, temperature change, hormones, stress
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8
Q

Neurotransmitters in sweating

A
  • Once triggered, the hypothalamus sends messages down the spinal cord via neurotransmitters
  • The neurotransmitters travel down the spine via ganglion or sympathetic nerves
  • These ganglions travel to nerves, which reach the skin’s surface
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9
Q

Role of neurotransmitters

A
  • Neurotransmitters act as “vehicles,” transmitting information from the hypothalamus to the skin’s surface
  • The neurotransmitters can “exit” at various places along the spinal cord. The “exit” determines the location of skin innervation.
  • T2-T4 = innervation of skin of face, T2-T8 = innervation of skin of upper limbs, T4-T12 = innervation of skin of trunk, T10-T12 = innervation of skin of lower limb
  • Acetylcholine (Innervates eccrine sweat glands)
  • Catecholamines (Innervate apocrine sweat glands)
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10
Q

Sweat production

A
  • Once innervated, the apocrine and eccrine glands will produce SWEAT
  • Contains sodium, chloride, potassium, lactate, urea
  • Clear hypotonic solution, pH ranges from 4-6.8
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11
Q

What serves as the body’s thermoregulatory center?
o The hypothalamus
o The adrenal cortex
o The frontal lobe

A

Hypothalamus

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12
Q

What neurotransmitter innervates eccrine sweat glands?
o Acetylcholine
o Catecholamine
o Glucose

A

Acetylcholine

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13
Q 
The hypothalamus can be triggered by all these except:
o	Stress
o	Exercise
o	Obesity
o	Temperature change
A

Obesity

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14
Q

Sweating disorders

A
  • Anhydrosis

- Hyperhydrosis

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15
Q

Anhydrosis

A

o Inability of the body to produce and or deliver sweat to the skin surface
o General: hypothalamus problems (tumor, heat stroke, mechanical trauma, congenital defects)
o Localized: polio, multiple sclerosis, alcoholic neuritis, diabetic neuritis, atrophy of the gland, radiation dermatitis

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16
Q

Hyperhydrosis

A

o Increased eccrine sweating (Emotional hyperhidrosis, Thermoregulatory hyperhidrosis)
o Diagnosed in 2.8% of the U.S. population
o 70% of those with symptoms do not consult a physician
o Peaks in early adulthood

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17
Q

Changes seen in hyperhydrosis

A
  • Hyperhidrosis is a state of excessive sweating of the axilla, palms, soles, or face that interferes with daily activities
Involves the eccrine sweat glands, however:
o	Sweat glands are NORMAL
o	No change in size
o	No change in shape
o	No change in number
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18
Q

Hyperhidrosis patient presentation

A
  • Main complaint is social embarrassment from wetness of hands and odor of feet
  • May have pruritis, burning and blistering from increased moisture
  • Increased incidence of dermatophyte, bacterial and viral infections
  • Leads to tinea pedis, pitted keratolysis and verrucae
  • May sweat so much that it beads up on toes and hands or drips
  • Either present with erythematous, shiny feet from the moisture or pale, boggy thick soles from absorption of excessive moisture (bromhidrosis)
  • Often requires treatment
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19
Q

Bromhidrosis

A
  • Foot odor or sogginess – end stage hyperhydrosis
  • Apocrine or eccrine
  • Foul smell
  • Bacterial decomposition of epidermal lipids and fatty acids
  • Propionibacterium is responsible for the cheesy odor
  • Tenderness (Blistering & fissuring of intertriginous and weight-bearing areas)
  • Moisture induced growth of many micro-organisms
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20
Q

Different forms of hyperhidrosis

A
  • General = secondary to a variety of conditions

- Focal = primary (idiopathic), associated with neuropathies, secondary to spinal disease/injury

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21
Q

Cause of primary or idiopathic hyperhidrosis

A
  • Exact cause is unknown
  • Familial or genetic?
  • Excessive Sympathetic Activity (constant stimulation)
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22
Q

Those diagnosed with hyperhidrosis have abnormal eccrine sweat glands.
o TRUE
o FALSE

A

False

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23
Q
  • Hyperhidrosis involves which sweat gland type?
    o Apocrine
    o Eccrine
A

Eccrine

24
Q

Hyperhidrosis/bromhidrosis treatment goals

A

o Reduction of moisture

o Reduction of bacterial population

25
Q

First line therapy for mild cases

A

o Foot gear: Should be non-occlusive, leather or canvas, avoid synthetic materials like plastic (Open sandals)
o Socks: Should be absorbent wool/synthetic blend. Avoid nylon and all cotton. Change midday
o Talc
o Tolnaftate: zeasorb powder-45% microporous cellulose, twice the absorbancy of talc

26
Q

Therapy for odor

A

Activated charcoal inserts

27
Q

Therapy for antipersperant and astringent effects

A

o Aluminum chloride hexahydrate (i.e. Drysol)
o Burows solution (1:10 to 1:40 conc.)
o Aluminum sulfate
o Calcium acetate

28
Q

What is the NUMBER ONE CHOICE for antipersperant effects?

A

DRYSOL***

  • astringent, antibacterial, and antifungal properties
  • effective for tinea pedis
  • NUMBER ONE CHOICE
  • skin should be completely dry, applied at bedtime
  • more effective if occluded
  • initial tx: 3-5 nights until controlled then once every 4-5 days.
29
Q

What are the treatment options for moderately severe cases - bromhidrosis?

A

Aldehydes, which produce a blockage within the stratum corneum

“I’ve never used any of these”

30
Q

Examples of aldehydes used for the treatment of bromhidrosis (moderate cases)

A
  1. Formalin (5-10%)
    - Potent wide-spectrum antiseptic and germicide
    • Very irritating to skin
  2. Glutaraldehyde
    - Germicidal, sporicidal and anhydrotic with constant use
    - Can cause brown discoloration
    - 10% solution, soak feet 3 times/wk for 1-2 week
  3. Methenamine gel
    - For moderate hyperhidrosis of soles
    - No contact sensitization
31
Q

How does treatment work?

A
  • The metal ions in the topical antiperspirant damage the lining of the sweat gland.
    As damage continues, a PLUG is formed over the sweat gland.
  • Sweat production never ceases, the gland is simply plugged
  • Sweating will return as the skin undergoes regeneration or shedding
  • Therefore…topical treatment is NOT a cure!
32
Q

Topical Treatments work by ________ sweat glands.
o Destroying
o Plugging
o Melting

A

Answer: plugging

33
Q

Iontophoresis

A
  • Used for palmar and plantar hyperhidrosis
  • Passage of direct electrical current onto skin’s surface
  • Device can be purchased for home use
  • Sit with hands or feet in shallow tray of water
  • Allow 15 – 20 milli-amps of electrical current to pass through water
  • Use for 10 days, 30 minutes each day
  • Maintenance therapy needed
34
Q

Contraindications for ionophoresis

A
  • Who are pregnant
  • Have pacemakers
  • Have metal implants
  • Have cardiac conditions
  • Have epilepsy
35
Q

Systemic treatment

A
  • Anticholinergics can be used in treating hyperhidrosis
  • Ex: glycopyrrolate, oxybutynin, benztropine, propantheline
  • Most effective for cranio-facial hyerhidrosis
  • May consider other anti-anxiety medications as well
36
Q

Treatment with anticholinergics

A
  • Long term therapy is required
  • Limited use in treating hyperhidrosis
  • Only 21% effective

Major side effects:
o Dry mouth, dry eyes
o Constipation, difficulty with urination
o Blurred vision

37
Q

Anticholinergics block transmission of
o Catecholamines
o Epinephrine
o Acetylcholine

A

Acetylcholine

38
Q

Botox injections

A
  • Botox injections can be used to treat axillary, palmar, and plantar hyperhidrosis
  • Analgesic applied prior to injection
  • Nerve block applied to ulnar or radial nerve prior to palmar injection
  • Starch Iodine test done prior to injection
  • Delineates areas of excess sweating with black-purple discoloration of the skin
  • Botox blocks the release of acetylcholine at the site of the neuromuscular junction.
  • Sweat glands are not stimulated, and sweat production ceases
  • Pros - Lasts 6-7 months, 90% effective
  • Cons: Very painful to the palms and soles of feet, expensive: $1400-$1600 per treatment
39
Q

Local excision

A
  • Used only for axillary hyperhidrosis
  • Starch Iodine test done prior to excision
  • Performed under local anesthesia
  • Vasoconstrictor applied to axillary region
  • Small incisions made
40
Q

Endoscopic thoracic sympathectomy

A
  • Last treatment option- PERMANENT
  • Uncommon for plantar hyperhidrosis
  • Surgery performed under general anesthesia
  • Goal of surgery is to excise or ablate the ganglion that innervate the sweat glands
  • Performed most frequently for palmar hyperhidrosis
  • Performed through thorascope or video
  • Minimally invasive
41
Q

What is pitted keratolysis?

A

o Associated with hyperhidrosis, not an actual sweat gland disorder
o Superficial infection
o Caused by several different bacteria
o Small, circular “punched out pits” in stratum corneum
o Can conjoin to form bizarre patterns on foot
o Common in children and adolescents, Boys>Girls

42
Q

Etiology of pitted keratolysis

A

o Primary isolate corynebacterium with no odor
o Primary isolate micrococcus sedentarius with odor
o Others: Streptomyces, Dermatophilus congolensis
o Not easy to culture bacteria, need to grind up stratum corneum to find it

43
Q

Treatment for pitted keratolysis

A

MAINSTAY TREATMENT

  • Topical 2% erythromycin solution or gel x 2 wks – MOST COMMON
  • Topical 1% clindamycin solution or gel x 2 wks
44
Q

Details on treatment options for pitted keratolysis

A

o Similar to that of hyperhidrosis, but also have to treat bacterial infection.
o Eliminate shoes and socks that don’t “breathe well”
o Astringent foot soaks to control the hyperhidrosis
o Benzoyl peroxide (antibacterial and anti-keratolytic)
o In severe cases, oral Erythromycin 1g daily x 2 wks

But remember…
- Mainstay is a topical antibiotic solution/gel for 2 weeks (erythromycin* or clindamycin)

45
Q

What is porokeratosis plantaris discreta?

A

AKA Intractable plantar keratoma or IPK
o Hyperkeratosis (of epidermal sweat duct)
o 1-3mm diameter punctate lesion, white or yellow
o Caused by pressure on weight bearing aspect of plantar skin
o Tender with side to side pressure and direct
o Non-vascular on debridement
o Debate as to whether the sweat gland is involved with cause
o Sweat duct is dilated below plug, not likely the cause
o May get up to 1.5cm in depth, histologically similar to tyloma and heloma

46
Q

Treatment of porokeratosis plantaris discreta (or IPK)

A

o Topical keratolytics
o Debridement
o Padding
o Intralesional injection of alcohol sclerosing solution
o Enucleation of plug and dessication of base
o Surgical excision

47
Q

Eccrine poromas

A

Note: can also be apocrine in origin

  • Benign Lesion- derived from cells of the terminal duct and connected to the epidermis
  • Slow growing, painless nodule
  • May present as superficial and smooth-surfaced or flat lesion
  • Resembles a pyogenic granuloma, dermatofibroma, or amelanotic melanoma
  • Rubbery and firm
  • Can get as long as 3 cm in diameter
  • May get infected or ulcerate
  • Found on surface
  • interdigital, toes, palm, soles
  • Affects mostly women in 4th decade
  • Tx: surgical excision and electrodessication
  • Must rule out malignancy
48
Q

Describe dyshidrosis

A
  • Not actually due to “bad/excess” sweating – the name is a misnomer
  • Dyshidrotic Eczema or Pompholyx
  • Small, fluid filled vesicles (looks a lot like pustual tinea or athlete’s foot)
  • Palms and soles – painful
  • Last for 3-4 weeks, intense pruritus, blisters, then dry and crack to fissures
49
Q

Etiology of dyshidrotic eczema

A 
o	Unknown
o	Associated with atopic dermatitis
o	Associated with asthma and hay fever
o	Eruptions are seasonal in above patients
o	Associated with neurotic history
50
Q

Differential diagnosis for dyshidrosis

A

o Fungal Etiology

o Must rule out fungal cause – KOH, biopsy

51
Q

Risk factors for dyshidrosis

A

o 2:1 female to male ratio
o Stress
o Exposure to metal salts (chromium, cobalt, nickel) through cement or mechanical work
o Seasonal allergies
o Occupation with frequent exposure of skin to a wet environment

52
Q

Treatment for dyshidrosis

A
  1. Topical creams: corticosteroid cream or ointment
  2. Wet compresses
  3. Antihistamines
  4. Oral steroid
  5. UV light therapy
  6. Botulinum toxin, for severe cases only

NOTE:
o Recurrence is common
o Avoid triggers

53
Q

Keratodermas

A
  • Not truly a sweat gland disorder
  • May be related to anhydrotic state
  • Localized or regional
  • Similar in appearance to diffuse or isolated hyperkeratosis
  • May have systemic manifestations
  • Most are inherited, autosomal dominant**
54
Q

Diffuse keratoderma

A
  • Diffuse hyperkeratosis
  • Palmar and plantar skin
  • So thick the skin cracks and fissures
55
Q

Palmoplantar keratoderma treatment

A 
It is persistent and difficult to treat
o	Debridement with topical keratolytics
o	Sharp debridement by scalpel
o	Topical vitamin A and emollients
o	Cushioned or shock absorbing insoles to reduce pressure
56
Q

FOCUS

A
  • Sweating – hyperhidrosis, pitted keratolysis (KNOW TREATMENT**) – pediatrics treatment
  • Some of these have some sort of an obscure association with sweating but not necessarily a direct effect

#2 Derm (13 decks)

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