Sweat glands Dan Flashcards
which condition are exacerbated by sweating?
Bromhidrosis Susceptability to development of contact dermatitis Miliaria Keratolysis Exfoliativa Juvenile Plantar dermatosis Transient Acantholytic dermatosis Hailey-Hailey disease
Which genoderms can cause hyperhidrosis?
Palmoplantar keratoderma Pachyonychia Congenita Congenital Icthyosiform Erythroderma (bullous & non-bullous) Dyskeratosis Congenita Nail Patella syndrome EB simplex>junctional Apert syndrome Dermatopathia pigmentosa reticularis Pachydermoperiostosis
NB these are the major cortical causes of secondary hyperhidrosis along with
Hereditary Sensory & autonomic neuropathies
What are the causes of central hypothalamic hyperhidrosis?
Infection, febrile illnesses
Malignancies - lymphoma, phaeo, carcinid
Vasomotor - SLE, RA, Raynauds, MI, reflex symp dyst
Neurologic - abscess, tumour, stroke
Drugs - alcohol, opiates, NSAIDs, catecholamines
Others - POEMS syndrome, diabetic neuropathy
Which genoderms can cause hypohidrosis?
Ectodermal Dysplasias
Incontinentia Pigmenti
Fabry disease
Bazex
What skin conditions cause obstruction of sweat glands?
Ichthyoses
Psoriasis
Eczematous dermatoses
Bullous diseases
T/F
Eccrine glands open directly to skin surface
True
apocrine glands open into a hair follicle
Where are apoeccrine glands found?
In the axilla in adults
Which sites have no eccrine glands?
lips, ear canal, clitoris and lab minora
T/F
sweat glands become fully functional about 1 year of age
False
age 2
T/F
adrenergic synapses innervate sweat glands
False
sympathetic innervation but synapses are muscarinic cholinergic not adrenergic
however ciculating catecholamines also stimulate sweat glands
Which 3 higher centres control sweating centrally?
- hypothalamic (thermal)
- medullary (gustatory)
- cortical (mental/emotional)
T/F
Primary hyperhidrosis may be inherited in an autosomal dominant fasion
True
What are the diagnostic criteria for primary hyperhidrosis?
- Focal, visible excessive sweating
- Present for 6 months or more
- No secondary cause identified
- At least 2 of;
At least one episode per week
Bilateral and symmetrical
Onset less than 25 yrs old
Impairs ADLs
Stops when sleeping
Fam Hx
T/F
palpmoplantar hyperhidrosis may start in childhood
True
usually childhood or puberty
axillary HH doesnt start until puberty
T/F
axillary hyperhidrosis is more common than volar (palmoplantar)
False
slightly less common
T/F
axillary hyperhidrosis is associated with body odour
False
excess sweat is eccrine and bromhidrosis is rare
T/F
Craniofacial hyperhidrosis is the same as gustatory sweating
False
Is excess sweating of head presenting in middle age
Triggered by heat, exercise, eating
What are the broad causes of secondary hyperhidrosis?
Central (CNS) -hypothalamic (thermal) -medullary (gustatory) -cortical (mental/emotional) Peripheral nerves sweat glands
T/F
Frey’s syndrome occurs in the distribution of the maxillary nerve (CNV2)?
False
Usually in distribution of auriculotemporal nerve - temple and temporal scalp; branch of CNV3
Chorda tympani syndrome is variant – sweating along jaw and chin
T/F
Frey’s syndrome occurs in 5% of pts undergoing parotid surgery
False
40%
Other than parotid surgery what can cause Frey’s syndrome?
syringomyelia encephalitis sympathectomy, thyroidectomy lung cancer subclavian aneurysm
What spinal cord pathology can cause secodnary hyperphidrosis?
SSS for Secondary Spinal Sweating
Spinal injury
Syringomyelia
Syphylis - Tabes dorsalis
T/F
in spinal injuries causing hyperhidrosis there is often loss of thermal sweating in skin below the level of the spinal injury
True
What is autonomic dysreflexia?
due to spinal injury at or above T6
During attacks there is massive sympathetic discharge causing sweating above the level of cord transaction + hypertension, tachy or brady cardia, flushing, headache, piloerection and paraesthesias
In these pts, direct stimulation of a sympathetic axon can cause sweating in a localised area of skin
Can be triggered by inflammatory mediators from skin conditions inc psoriasis and dermatitis
What are the common causes of compensatory hyperhidrosis
Miliaria – recurrent miliaria rubra or profunda leads to non-functioning sweat glands of trunk often followed by comp hyperhidrosis of face
Diabetes – autonomic neuropathy causes hypo or anhidrosis esp of legs. Comp hyperhidrosis can be gustatory on face and neck or thermal on back
Post sympathectomy (including for hyperhidrosis)
what is cold erythema?
rare condition where cold causes pain, erythema and central area of hyperhidrosis
which conditions can cause hyperhidrosis due to abnormalities of the eccrine glands?
Eccrine naevi Palmoplantar keratoderma Eccrine angiomatous hamartoma Maffucci syndrome AV fistula Klippel-Trenauney syndrome Glomuvenous malformation Blue rubber bleb naevus syndrome Granulosis rubra nasi (see later) Pretibial myxoedema
What is the grading of volar hyperhidrosis?
Mild – moist palm or sole, no visible sweat droplets
Morerate – sweating involving distal fingers
Severe – dripping sweat
What is the grading of axillary hyperhidrosis?
Assess Size of sweat stain on clothes;
20cm severe
How is the starch iodine test performed?
Apply iodine as 3.5% in alcohol to skin and allow to dry
Brush on starch powder (cornstarch) or paint on starch in castor oil
Mixture turns blue-black at sites of sweating
T/F
primary volar and axillary hyperhidrosis gets worse with age
False
often resolve after age 25
what is treatment ladder for hyperhidrosis?
Antiperspirants
o 20% aluminium chloride hexahydrate (Driclor)
o Zirconium salts – can help axillae but not volar surfaces
Topical anticholinergics
o 0.5% glycopyrronium bromide cream for gustatory hyprhidrosis
o 2% glycopyrronium aqueous solution for scalp hyperhidrosis
Topical aldehydes
o 1% formalin (formaldehyde) soaks for plantar hyperhidrosis (not for other sites)
o Gulteraldehyde 10% buffered solution pH 7.5 swabbed onto feet 3x per week
Iontophoresis
o Can use tap water or glycopyrollate
Oral anticholinergics
o Propanthelene bromide – 15mg-150mg daily
o Glycopyrrolate – 1-2mg BD
o Oxybutinin – 1.25-5mg
Beta blockers - worsens if used long term
Clonazepam - if anxiety related
BoTox - axillary of volar
MiraDry microwave device
Surgery
o Excision of sweat gland containing axillary skin
o Destruction/removal of glands;curettage, liposuction
o Sympathectomy - VATS procedure
CBT - if anxiety related
T/F
Fabrys disease causes hypohidrosis
True
but can also cause secondary hyperhidrosis due to autonomic neuropathy
Sjogren’s also can cause hypohidrosis from direct destruction of glands and secondary hyperhidrosis due to autonomic neuropathy
What are the causes of sweat gland destruction?
Tumour eg. lymphoma Scleroderma or morphoea Sjogrens syndrome GVHD Acrodermatitis chronica atrophicans Deep burns XRT Drugs - 5FU, topiramate, topical aldehydes, aluminium slats or zirconium salts
What is Ross’s syndrome?
widespread hypohidrosis
w/ patchy hyperhidrosis
+ Holmes-Adie syndrome
(myotonic pupil and loss of deep tendon reflexes)
pupil has irreg outline and sluggish light reflex
what conditions cause hypohidrosis by peripheral/autonomic neuropathy?
Many potential causes e.g. DALE Diabetes Amyloidosis Leprosy Ethanol (alcoholisim) Also Fabry's Sjogren's
How is hypohidrosis managed?
Treat cause/stop drug if possible
Keep cool – avoid overheating
For disorders of keratinisation with anhidrosis treat aggressively with keratolytics with aim to restore sweating
Spray water can help cooling
Regarding Miliaria crystalina;
who gets it?
what body sites?
what is the level of sweat duct obstruction?
Neonates under 2 wks
- Others in hot climates
Face and trunk
stratum corneum
Regarding Miliaria rubra;
who gets it?
what body sites?
what is the level of sweat duct obstruction?
Neonates, children, adults esp in hot climates
Neck and upper trunk
Mid epidermis
Regarding Miliaria profunda;
who gets it?
what body sites?
what is the level of sweat duct obstruction?
Adults in hot climates on exertion only
- Often follows several episodes of Miliaria rubra
Trunk and prox limbs
DEJ
T/F
Miliaria crystalina is the most common type of miliaria
False
Rubra is
AKA ‘prickly heat’
T/F
Periporitis is a complication of any type of Miliaria
True in theory
But most often complicates miliaria rubra
T/F
Miliaria pustulosa is an infective complication of miliaria rubra
False
pustular but sterile
T/F
Miliaria rubra can cause hyperpyrexia if extensive
True
so can miliaria profunda
T/F
Compensatory hyperhidrosis is seen in Miliaria rubra
False
seen on face in miliaria profunda
T/F
Miliaria profunda is the most short lived form of miliaria
True
Regresses within hrs of ceasing exercise/cooling
– differentiates it form other causes of papules which are usually more persistent
T/F
sweat gland abscesses are cold abscesses
True
not fluctuant, dont point
T/F
sweat gland abscesses are sterile
False
usually due to staph
= Periporitis staphylogenes
T/F
sweat gland abscesses are associated with innune deficiency
False
not particularly
T/F
Pts w/ widespread idiopathic calcinosis cutis excrete calcium in sweat
True
What is ‘ureamic frost’ on the skin?
CRF pts with uraemia excrete urea in sweat causing a ‘ureamic frost’
NB ureamic pts often alos have reduced size of sweat glands on histo
T/F
Body odour is caused by bacterial degradation of apocrine sweat yielding ammonia and short chain fatty acids which cause smell
True
What is Bromhidrosis
Bromhidrosis is smelly sweat of any cause
Most often its ‘keratogenic’ due to maceration of the SC and bacterial colonization which produces the odou
T/F
Apocrine bromhidrosis can occur at any aporcrine site
False
Apocrine bromhidrosis only affects the axillary region – other apocrine sites don’t produce odour
T/F
Bromhidrosis is only caused by aprocrine sweat
False
can be apocrine or eccrine
T/F
Pts with apocrine bromhidrosis often have more and larger axillary apocrine glands than normal
True
T/F
Pts with apocrine bromhidrosis have altered local flora with reduced corynebacteria
False
altered local flora including increased corynebacteria
What are the aetiologies of eccrine bromhidrosis?
Keratogenic
Metabolic (syndromes)
Exogenous
Which sites are most commonly affected by keratogenic eccrine bromhidrosis?
Intertriginous sites
plantar region
Which syndrome gives a musty or mousy smell to the sweat?
PKU
What is the cause of fish odour syndrome?
Trimethylaminuria
deficiency of flavin-containing monooxygenase3 (FOM3)
so cannot fully metabolise trimethylamines, choline or lecithin (marine fish, kidney, eggs, liver)
get fishy odour when they eat these things due to excretion triemthylamines in the sweat
T/F
Methionine malabsorption syndrome results in boiled cabbage odour of the sweat
False
causes oasthouse syndrome - smells like drying hops
Boiled cabbage odour is caused by Methionine adenosyltransferase deficiency
Which metabolic syndrome causes a sweet smell of the sweat and urine?
Maple syrup urine disease
T/F
Pts with Trimethylaminuria get eccrine bromhidrosis with a sweaty feet smell
False
Sweaty feet odour typical of Isovaleric acidaemia
Trimethylaminuria causes fish odour syndrome
Which foods and drugs can cause eccrine bromhidrosis?
Foods – garlic, asparagus, curry
Drugs – penicillins, bromides
Chemicals - DMSO
what is management of bromhidrosis?
Ascertain if pathological or not
Encourage good hygiene
Avoid garlic, asparagus, curry
Acidic deodorant can help reduce bacteria
Ablation of axillary sweat glands can be offered if troublesome – laser, liposuction, ultrasound ablation, MiraDry, surgery
What is the classification of chromhidrosis?
Apocrine chromhidrosis
(true) Eccrine chromhidrosis
(eccrine) pseudochromhidrosis
What are physiopathological causes of eccrine chromhidrosis?
hyperbilirubinaemia (green)
alkaptonuria (black) (ochronosis)
Where is Apocrine chromhidrosis apparent? What causes it?
Face, axillae, areolae
Black/brown/green/blue/yellow
Due to excess secretion of lipofuscins from the sweat gland
What are investigations for chromhidrosis?
FBC, ELFT w/ split bilirubin skin swabs for smear and microscopy skin biopsy urinary homogentisic acid \+/- spectrophotometry tests
What are the causes of pseudochromhidrosis?
Sweat is normal but gets coloured at the skin surface by a pigment e.g.
chromogenic bacteria (corynebacteria, piedraia, pseudomonas)
clothing dye
copper deposits
What is granulosis rubra nasi?
Rare AD disease hyperhidrosis of nose tip onset in childhood followed later by erythema and sometimes papules and vesicles No associations No good Rx often resolves at puberty
T/F
Neutrophilic eccrine hidradenitis is a cytotoxic side effect of chemo drugs on the eccrine glands
True
which drugs cause Neutrophilic eccrine hidradenitis?
Cytarabine for AML is most typical
– onset 1-2 weeks after chemo
Also MTX, cyclophosphamide, anthracyclines, 5FU, bleomycin, vinca alkaloids, imatinib
Can occur locally at sites of bleomycin injection
Has been triggered by paracetamol
Can be post G-CSF in HIV pts
What are non-drug causes of Neutrophilic eccrine hidradenitis?
infections
– strep, staph, gram neg bacilli, HIV
T/F
Neutrophilic eccrine hidradenitis can be papules, plaques, linear, targetoid or polymorphic erythematous lesions
True
can also be purpuric and pustular
Typically face and extremeties
T/F
pts with neutrophilic eccrine hidradenitis are often febrile
True
due to infection or drug AE
What is the histopathology of neutrophilic eccrine hidradenitis?
vacuolar degeneration of eccrine glands sparing hair follicle
neutrophilic infiltrate (may be lymphocytic if pt neutropenic)
eccrine squamous syringometaplasia
(squamous metaplasia of cuboidal epithelial cells of eccrine ducts)
T/F
Idiopathic palmoplantar hidradenitis is a rare condtion mainly seen in children esp after intense physicial activity
True
T/F
Idiopathic palmoplantar hidradenitis is characterised by sudden onset of multiple tender erythematous nodules on the palms most often and sometimes also on the soles
False
soles mainly, sometimes also palms
What is the histo of Idiopathic palmoplantar hidradenitis?
Neutrophilic infiltration of the eccrine glands and ducts
Infiltrate is nodular and may be abscesses
T/F
Idiopathic palmoplantar hidradenitis resolves in days to weeks with rest but may be recurrent in up to 50%
True
What are DDs of Idiopathic palmoplantar hidradenitis?
Pseudomonas hot foot syndrome
Erythema nodosum or other panniculitis
Perniosis
Vasculitis esp PAN
What is Fox-Fordyce disease?
AKA Apocrine miliaria
V itchy condition of unknown cause
Mainly women age 15-35
Dome-shaped skin-coloured perifollicular papules in axilla + periareolar and anogenitial skin
Can be seen on medial thighs, periumbilical area and sternum
Often hair is lost from affected sites
What are exacerbating factors in Fox-Fordyce disease?
Worse by heat, excercise, emotional stress
Often better in pregnancy or with OCP
What is histo Fox-Fordyce disease?
keratin plug in the follicular infundibulum obstructing the apocrine duct
rupture of duct and inflammation
spongiosis and Perifollicular and periadnexal infiltrate of lymphocytes
What is treatment ladder of Fox-Fordyce disease?
TCS 1st line (caution due to flexural sites) ILCS 1st line (caution risk of atrophy) Topical calcineurin inhibitors Topical tretinoin can help pruritus Clindamycin lotion BD can reduce symptoms OCP helps some women Isotretinoin has been used Phototherapy Electrocautery Excision of periareolar skin
