Axillary bromidrosis is a combination of hyperhidrosis and osmidrosis1 and is a distressing condition that poses significant social embarrassment in almost all countries worldwide. However, the definite cause of bromidrosis has not yet been determined. To summarize the possible causes, an English literature search from 1975 to June of 2007 was performed for articles with references to bromidrosis. In conclusion, axillary sweat glands may play the most important role in the cause of bromidrosis. In addition, axillary microorganisms, hormones, and inherent causes also contribute to bromidrosis.
First, osmidrosis is characterized by excessive odor that originates in apocrine glands, whereas hyperhidrosis is a condition of excessive sweating from eccrine glands.1 Reasonable removal of axillary sweat glands has achieved a satisfactory outcome for most patients. A bewildering multitude of surgical methods has been reported to date, which can be classified into three classic types: (1) a method that removes only subcutaneous cellular tissue without removing skin, (2) a method that removes skin and subcutaneous cellular tissue en bloc, and (3) a method that partially removes skin and cellular tissue en bloc and removes the subcutaneous cellular tissue of the adjacent area. It is thus evident that the definite location of axillary sweat glands has not yet been determined. Also, it is important to identify where the three types of sweat glands are in the axillae. As histologic findings suggest, eccrine glands are dominant in the dermis, but most apocrine glands are located in subcutaneous tissue. In recent publications, it has been a trend to carry out a prospective histologic study on axillary biopsy specimens by means of various immunohisto-chemical markers beyond routine stains. The popular markers include CD15, CD44, human milk fat globulin-1, and S-100 (Table 1).
Next, it is believed that the malodor is composed of E-3-methyl-2-hexenoic acid, which is liberated from nonodorous apocrine secretions by axillary microorganisms. Zeng et al.2 reported that in the apocrine gland secretions, E-3-methyl-2-hexenoic acid was carried to the skin surface bound to two proteins, the structures of which structures are shown in Figure 1. Leyden et al.3 claimed that although there were some types of microorganisms residing in axillary flora, including Micrococcaceae, aerobic diphtheroids, and propionibacteria, only diphtheroids generated typical body odor.
Furthermore, apocrine glands of human axillae are a major source of odorous signals and pheromones, which do not function until puberty. According to Beier et al.,4 androgen receptors were located in the nuclei of apocrine secretory epithelium and estrogen receptor β was located in the nuclei of apocrine secretory epithelium and in cytoplasm, and apocrine glands lacked estrogen receptor α.
In addition, most of the patients have family members who also suffer bromidrosis. An autosomal dominant inheritance pattern was proposed in one study.5
Song-Lin Yang, M.D.
Jiang-Hong Zheng, M.M.
Department of Plastic Surgery
Shanghai No. 6 People’s Hospital
Shanghai Jiao Tong University
Shanghai, People’s Republic of China
1. Inaba M, Anthony J, Ezaki T. Radical operation to stop axillary odor and hyperhidrosis. Plast Reconstr Surg.
2. Zeng C, Spielman AI, Vowels BR, Leyden JJ, Biemann K, Preti G. A human axillary odorant is carried by apolipoprotein D. Proc Natl Acad Sci USA.
3. Leyden JJ, Mcginley KJ, Hlözle E, Labows JN, Kligman AM. The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol.
4. Beier K, Ginez I, Schaller H. Localization of steroid hormone receptors in the apocrine sweat glands of the human axilla. Histochem Cell Biol.
5. Hurley HJ. Diseases of the Eccrine Sweat Glands
. Philadelphia: Saunders; 1992.
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.