BC04: Apocrine chromhidrosis of the bilateral cheeks

A. Kelly, R. Gandhi and J. Natkunarajah

Dermatology Department, Kingston Hospital, London, UK

A 32-year-old woman presented with a history of coloured sweating since the age of 16 years. The patient described the skin over her cheeks becoming heated, which was followed by blue-coloured sweat. She had no discolouration over the axilla, groin, hands or feet. She described a residual blue tinge on her cheeks, which was present on her towels and clothing after wiping. She had tried capsaicin cream 8 years previously, which improved her condition but it led to skin irritation and subsequent cessation. She had no medical history except for acne. This had been treated with isotretinoin. On examination, there was blue speckling localized to her cheeks, which was consistent with chromhidrosis. There was no evidence of involvement of other body areas. The skin was otherwise normal. The patient declined skin biopsy. Skin scrapings and swab culture were negative for chromogenic bacteria. Her liver function and kidney tests were normal. The patient is awaiting approval of a funding application for botulinum toxin injections, which may prove helpful through blockade of cholinergic stimulation and inhibition of substance P release. Apocrine chromhidrosis is a benign chronic condition. It starts during puberty and tends to abate with age, when sweat glands recede. It is thought to result from higher-than-normal concentrations of lipofuscin pigment granules in apocrine glands or higher-than-normal oxidation of lipofuscin [Semkova K, Gergovska M, Kazandjieva J, Tsankov N. Hyperhidrosis, bromhidrosis, and chromhidrosis: fold (intertriginous) dermatoses. Clin Dermatol 2015; 33: 483–91]. This leads to blue-, yellow-, green- or black-coloured sweat. It must be differentiated from pseudochromhidrosis as a result of yeast, in particular Malassezia furfur, and bacilli, which have been associated with blue sweat; eccrine chromhidrosis, which tends to be more widespread and also more concentrated on the palms and soles; and ochronosis, which can lead to blue–black discolouration of the skin, particularly around sweat glands secondary to alkaptonuria, quinacrine, quinine or excessive hydroquinone use.