An Interesting Case of Orange Colored Sweat

Section 27 Case Studies
Chapter
178
An Interesting Case of
Orange Colored Sweat
SS Lakshmanan
ABSTRACT
A 35-year-old female presented with colored staining of her dresses,
undergarments and colored sweat over face for 15 days (Figures 1
and 2). On inspection, the secretion was odorless and yellowish orange
in color. On investigation, no significant laboratory abnormalities were
noted. Urine examination was normal. Grams stain and cultures of skin,
scrapings from the affected area and skin biopsy was done.
CASE REPORT
A 35-year-old female presented with history of colored sweat over the
face and neck along with staining of her dresses and undergarments.
The colored sweat causing discoloration of face was easily removable
with soap and water, but would reappear later. She was a housewife.
No history of prolonged exposure to any drugs, no recent history
of intake of any colored foods, no history of exposure to any dyes,
paints, coal or any other chemicals. Urine, saliva and tear color was
normal. All baseline investigations including urine examination
were found to be normal.
• Urine homogentisic acid levels were normal
• Bleeding and clotting time were normal
• Liver function tests were normal
• Blood and urine cultures were negative
• Scrapings from the skin and biopsy results were inconclusive
(Figure 3).
Figure 1: Colored sweat over the face
DISCUSSION
Sweat glands are small tubular structures of the skin that produce
sweat. There are two kinds of sweat glands: (1) eccrine and (2)
Apocrine sweat glands, which are referred to as sudoriferous glands.
Eccrine and Apocrine Glands
The eccrine glands are found all over the body and function
throughout our life. They secrete a clear, odorless fluid that serves to
regulate body temperature.1
Apocrine glands develop during puberty and are most active
throughout adulthood and are located in the armpits, areolar,
genital, and anal areas. Apocrine glands secrete a thick, milky sweat
that, once broken down by bacteria, is the main cause of body odor
(Figure 4).2
Figure 2: Stained undergarment
Case Studies
Section 27
Figure 3: Biopsy site
Figure 5: Differential diagnosis for colored sweat
• Chromhidrosis was first case was described in 1709 by Yonge.
Limited research on etiology as it is a very rare condition and not
associated with systemic disorders.
Age
Chromhidrosis is noted after puberty, when the apocrine glands are
activated.
Pathophysiology and Etiology of Chromhidrosis
Lipofuscin is a yellowish brown pigment that is normally found in
the cytoplasm of relatively non-dividing cells. In chromhidrosis,
lipofuscins are found in a higher-than-normal concentration or
a higher-than-normal state of oxidation in apocrine glands. This
increased level of oxidation results in the green, blue and even black
sweat seen in chromhidrosis.
DIFFERENTIAL DIAGNOSIS (FIGURE 5)
Figure 4: Types of sweat glands
Source: Mayo Foundation for Medical Education and Research
Definition of Chromhidrosis and
Pseudochromhidrosis
• It is the production of colored sweat by eccrine or apocrine sweat
glands
• Eccrine chromhidrosis is very rare
• Chromhidrosis is most often apocrine in origin. Although
apocrine glands are found in the genital, axillary, areolar, and
facial skin, chromhidrosis is reported only on the face,3 axillae,4
and breast areola.5 It is brown, black, blue or green in color
• Pseudochromhidrosis is the production of colorless sweat, which
becomes colored when it reaches the skin secondary to some
offending agents like drugs, bacterial infections (cornybacterium),
coal, dyes, paints and colored foods.6,7
Incidence
772
• Incidence statistics are not available as chromhidrosis is rare.
There have been few reports of chromhidrosis in the literature
•
•
•
•
•
•
Hyperbilirubinemia
Pseudomonas infection
Bleeding diathesis
Alkaptonuria
Addison’s disease
Hemochromatosis
INVESTIGATIONS
No significant laboratory abnormalities have been noted with
apocrine chromhidrosis.
The following test may help to rule out other causes:
• Determination of complete blood cell counts to exclude bleeding
diathesis
• Tests of urinary homogentisic acid levels to exclude alkaptonuria
• Fungal and bacteriologic cultures to exclude infectious causes of
pseudochromhidrosis
• Wood lamp examination of colored sweat may be positive
• If no sweat is produced at the time of the test, manual expression
or pharmacologic stimulation with intradermal epinephrine or
oxytocin (Pitocin) can be used to stimulate sweat secretion
• Clothing fibers in contact with the secretions may also fluoresce
yellow-green with standard ultraviolet (UV) microscopy.8
Chapter 178 An Interesting Case of Orange Colored Sweat
Section 27
Histopathology in Chromhidrosis
Capsaicin
The apocrine glands appear normal in size and morphology, but the
number of glands varies. The increased number of yellow-brown
lipofuscin granules is observed in the cytoplasm of secretory cells
on routine hematoxylin-eosin staining (Figure 6). The granules
are positive on periodic acid, Schiff stains and demonstrate
autofluorescence under a UV excitation wavelength of 360–395 nm.
A few reports have described successful treatment of chromhidrosis
with capsaicin cream.13,14 Capsaicin, a crystalline alkaloid found
in red peppers, is commonly used for the temporary relief of pain
from rheumatoid arthritis, osteoarthritis, and neuralgias. Capsaicin
depletes neurons of substance P, a neurotransmitter important in
apocrine sweat production. Clinical relapse occurs when therapy is
stopped.
Treatment of Chromhidrosis
Apocrine chromhidrosis has no fully satisfactory cure or treatment.
Patients can manually or pharmacologically empty the glands to
achieve a symptom-free period of about 48–72 hours or until the
glands replenish the pigment. BOTOX is predominantly used to
decrease eccrine sweat in persons with hyperhidrosis. However,
recent reports demonstrated improvement of facial and axillary
chromhidrosis with BOTOX.9,10 BOTOX may suppress apocrine
secretion by blocking cholinergic stimulation and substance P
release (Figure 7).11,12
Pseudochromhidrosis (Figure 8)
The causative factor has to be removed and treatment with antibiotics
as infection is the most common cause.
COMING BACK TO THE CASE
This patient was presented with orange sweat and stained
garments. All investigations pertaining to chromhidrosis and its
differential diagnosis were negative, hence was considered as
pseudochromhidrosis probably secondary to some dietary habits or
infectious etiology and was treated with macrolide antibiotics for a
week and showed response.
Some Interesting Facts
Causes of Orange Sweats
• Certain lotions containing sun protection factor (SPF) ingredients
or sunless tanning lotions when used the orange sweat stains may
be caused by the pH of our sweat (too acidic).
• Certain foods like onions, garlic, cola, sodas and spicy foods in
large amounts cause colored sweat.
Some Different Colors of Urine
Red or Pink Urine (Figure 9)
• Blood
• Foods (beets, blackberries and rhubarb can turn urine red or
pink)
• Rifampin.
Orange Urine (Figure 10)
Figure 6: Oxidized lipofuscin granules
Figure 7: BOTOX
• Medications that can turn urine orange include rifampin; the antiinflammatory drug sulfasalazine, phenazopyridine (Pyridium),
certain chemotherapy drugs
• Dehydration
Figure 8: A case of topiramate induced pseudochromhidrosis which
subsided after drug removal15
773
Case Studies
Section 27
Figure 11: Showing different colors of chromhidrosis and
pseudochromhidrosis
Figure 9: Pink urine caused by food products which turned clear on
removal of the offending agent
CONCLUSION
Both chromhidrosis and pseudochromhidrosis are rare. Diagnosis
of chromhidrosis is based on biopsy and autofluorescence of
both skin specimens and stained clothing, while diagnosis of
pseudochromhidrosis is based primarily on history, and successful
treatment with antibiotics.
REFERENCES
Figure 10: Orange urine caused by drugs
Blue or Green Urine
WE CAN SWEAT IN DIFFERENT COLORS
Sweat can occur in different colors. It is either classified as Chromhidrosis
and pseudochromhidrosis. In Chromhidrosis the common thread is
that the color sweat is produced in the gland. This differentiates it from
pseudochromhidrosis where clear sweat is produced and mixed with a
colored agent when it reaches the skin (Figure 11).
774
• Blue diaper syndrome is an autosomal recessive metabolic
disorder caused by a defect in tryptophan absorption in children
• Green urine sometimes occurs during urinary tract infections
caused by pseudomonas bacteria.
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Anat Entwicklungsgesch. 1973;139(2):173-83.
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13. Marks JG. Treatment of apocrine chromhidrosis with topical capsaicin.
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