Red and Black Pseudochromhidrosis.

Sir,

Chromhidrosis and pseudochromhidrosis are rare skin disorders. Chromhidrosis is the production of colored sweat from sweat glands containing lipofuscin pigments. Chromhidrosis is mostly apocrine in origin. Eccrine chromhidrosis is very rare and occurs with the ingestion of certain drugs and dyes. Pseudochromhidrosis is production of colorless sweat, which becomes colored when it reaches the skin and comes in contact with extrinsic agents such as chromogenic bacterial products, fungi, dyes, paint, and colored foods.[12345678910] Here, we present two very rare interesting cases of red and black pseudochromhidrosis.

Case 1: A 9-year-old boy, with body weight of 28 kg, presented with progressive red discoloration of the face. He was undergoing treatment for cheilitis for 1½ month. A new emollient (containing urea, light liquid paraffin, white soft paraffin, and glycerol) was introduced 10 days back, and he started experiencing irritation, pain, and swelling of lips. The emollient was stopped with gradual remission of itching and pain. Five days back, he suddenly noted redness around the mouth which gradually spread all over the face. It became prominent while going to school during daytime and on sweating. Strangely, the redness disappeared when he returned home and took bath. He was apparently healthy, without any medical history, denied any drug intake in the last 2 months, as well as any bleeding from any other site. His family history was insignificant. The color of urine, stool, saliva, and tear was normal. Cutaneous examination revealed diffuse erythema on the face, mild exfoliation of skin on lips, and angles of mouth [Figure 1]. He was treated for allergic contact dermatitis and was prescribed two antihistamines, prednisolone equivalent to 15 mg and H2 blocker. Next day evening, the redness had spread all over the shoulder, abdomen, and progressed up to knee. However, the child was completely asymptomatic and redness completely disappeared after bath. The patient was advised on the telephonic conversation to stop all treatment and called for review. On the 3rd day morning, an odorless red-colored secretion was identified all over the body up to the knees [Figure 2a and b]. Normal-colored skin was revealed when rubbed firmly with absolute alcohol [Figure 2c]. No autofluorescence of sweat was noted under the Wood's lamp. A revised clinical diagnosis of pseudochromhidrosis was made. Routine biochemical examinations including clotting profile and urinalysis were within normal limit. Gram-staining and culture of skin swab from face did not reveal any organism. The child was advised erythromycin 250 mg thrice daily and topical clindamycin lotion twice daily. However, the clindamycin lotion had to be stopped as it caused severe pain and irritation on the lip. On the 4th day morning, all lesions had subsided except small rim of erythema around the mouth [Figure 3]. The patient was asked to continue oral erythromycin for 7 days. Although the patient never revisited the clinic, their parents informed via telephonic conversation. There was complete disappearance of lesions without any flare up in next 2 months. Clearance of lesions with antibiotic implied bacterial etiology. Perioral erythema, as in Figures 1 and 3, implied lip as the origin of infection. Our final diagnosis was pseudochromhidrosis due to secondary infection after irritant contact dermatitis to lips.

Figure 1

Reddish discoloration on face, mild exfoliation of skin on lips and angles of mouth

Figure 2

(a) An odorless erythematous secretion all over the body up to knee. (b) Erythematous secretion over left arm and forearm. (c) Erythematous stain on face removed by absolute alcohol

Figure 3

Faint perioral rim of erythema

Case 2: An apparently healthy 20-year-old male presented with darkening of both palms and right leg for the past 5 days [Figure 4a and b]. He denied intake of any unusual food, new drug, or vitamin supplements in the month before consultation. His sister was also suffering from similar complaint. Clinical examination revealed accentuation of eccrine palmar orifices with black secretion [Figure 4c]. However, it could not be manually excreted from the orifices. The secretion faded when rubbed with damp swab [Figure 5]. There was no autofluorescence under Wood's lamp. The color of urine, stool, saliva, and tear was normal. There was no history of psychological disorder. Routine biochemical tests were normal. Urine was negative for homogentisic acid. Gram-staining and culture of skin scrapings revealed Corynebacterium species and normal flora. The patient refused biopsy. Clinical diagnosis of pseudochromhidrosis was made. The patient was prescribed oral erythromycin 500 mg twice daily and topical clindamycin with complete resolution of lesions in 3 days [Figure 6]. Her sister was not investigated but asked to apply clindamycin solution alone. She also recovered. There was no recurrence in the next month.

Figure 4

(a) Black discoloration of both palms. (b) Black discoloration of right leg. (c) Black-dotted accentuation of palmar sweat gland orifices of right palm

Figure 5

Black stain faded by damp swab

Figure 6

Disappearance of lesion from palm

Eccrine and apocrine glands produce sweat. Clear and odorless secretion of eccrine glands serves to regulate body temperature. Apocrine glands secrete a thick, milky sweat that, once broken down by bacteria, is responsible for body odor.

Different subtypes of colored sweat have been described. (1) Apocrine chromhidrosis: Limited to areas of localization of apocrine glands such as the face, axilla, and areola due to higher lipofuscin concentration or its higher oxidative state. It is usually precipitated by some emotional stimulus, hot shower, or simple rubbing of skin; (2) true eccrine chromhidrosis: Less common generalized disorder mostly caused by ingested dye or drug; (3) pseudo-eccrine chromhidrosis or pseudochromhidrosis: Sweat produced is colorless but it mixes with a coloring agent (chromogenic bacterial products, chemicals, paints, or dyes) when it comes to skin. Several extrinsic causes of eccrine pseudochromhidrosis have been noted like Corynebacterium, piedraia, bacillus species, other fungi, dyes, drugs, and chemical contaminants [Table 1] (modified from Rodríguez-Martín et al.[7]). Laboratory studies should include complete blood count to rule out bleeding diathesis (hematohydrosis), bilirubinemia, urinary homogentisic acids to exclude alkaptonuria, and fungal and bacteriological culture of the affected area. In the first case, identification of the causative bacterial organism was not possible. However, diagnosis was made from clinical presentation, spread of lesions after starting systemic corticosteroids and successful treatment with antibiotics. In the second case, diagnosis was reached by clinical and microbiological feature and response to treatment. Complete clearance of the lesions in both these cases with antibiotics helped to rule out chromhidrosis.

Table 1

Pseudochromhidrosis in English literature

Chromhidrosis can be diagnosed by biopsy. Although botulinium toxin A and capsaicin preparations are used, there is no fully satisfactory treatment except surgical removal of apocrine glands. To the best of our knowledge, only 11 cases[12345678910] of pseudochromhidrosis have been reported. Barring only three cases,[124] bacteria played important role in all. Two cases of pseudochromhidrosis have been reported before from the Indian subcontinent. In both these cases, Gram-staining and culture of skin scrapings did not reveal any pathogen. However, dramatic clearance of lesions with antibiotics and absence of other causes of colored sweating suggested bacterial pseudochromhidrosis.[35]

By contrast, pseudochromhidrosis is easily treatable, as the cause is exogenous. To the best of our knowledge, red pseudochromhidrosis after irritant contact dermatitis of lip (and spread of lesions after intake of systemic corticosteroids) has never been documented. In the second case, black pseudochromhidrosis of two siblings was due to Corynebacterium infection, probably due to contact with external common source. Although black color of palms due to pseudochromhidrosis had once been mentioned in literature, black pseudochromhidrosis of leg had never been reported.

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Conflicts of interest

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