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Chapter
19 Disorders of the Skin Appendages

This chapter discusses disorders of the skin appendages: sweat glands, sebaceous glands, hair follicles and nails.
When these are affected by intrinsic or extrinsic factors, cosmetic appearance and the ability to regulate the body
temperature are affected. The diseases whose main lesions occur in the skin appendages are intro-duced in this
chapter (see Chapter 1 for the functions of skin appendages).

A. Disorders of the sweat glands

1. Miliaria
Synonym: Sweat retention syndrome

Outline
Commonly called heat rash, it is caused by obstruction
to the eccrine sweat ducts.
Skin care is the main treatment.

Clinical features, Classification

Miliaria is classified by the location of the obstructed sweat
ducts into miliaria crystallina, miliaria rubra and miliaria
profun-da (Fig. 19.1).
Miliaria crystallina
The sweat ducts are obstructed in or directly under the horny
cell layer, producing superficial transparent vesicles. Flushing is

19
sweat accumulation at the level of occlusion of sweat duct
horny cell layer
 occlusion
of sweat
duct

intraepidermal
sweat
accumulation
intradermal
sweat
accumulation
 miliaria crystallina miliaria rubra miliaria profunda

Fig. 19.1 Classification of miliaria, and obstructed portion of the sweat duct.
312
 A. Disorders of the sweat glands 313

not present. The vesicles soon dry and become thin, white
scales. They heal in one to several days without itching or
inflammation. They commonly occur on the face of infants;
however, they may appear accompanying fever in adults.
Miliaria rubra
It frequently occurs in an environment with high temperature Clinical images are available in hardcopy only.
and humidity, or in infants, the obese and persons with hidrosis
(Fig. 19.2). Inflammation occurs from obstruction of the sweat
ducts in the granular cell layer region, and rose pink papules of
1 mm to 2 mm in diameter are produced. It is accompanied by
flushing and itching. The trunk, extensor surfaces of the
extremi-ties, neck region and axillary fossae are most Fig. 19.2 Miliaria rubra after fever.
commonly affected. It often becomes eczematous (miliaria
eczematosa) or pustular (miliaria pustulosa).
Miliaria profunda
The sweat ducts are destroyed at the dermo-epidermal junc-
tion. Flat-surfaced, white papules without itching occur
secondar-ily after miliaria rubra.

Pathogenesis
The pathogenesis of miliaria is poorly understood. It is
Clinical images are available in hardcopy only.
thought that the sweat ducts are obstructed by eccrine
perspiration, affect-ing the sweat flow. Retained sweat leaks
into the peripheral tis-sue of the sweat ducts, causing eruptions.
Miliaria is easily caused when hyperhidrosis is present from
physical exercise in a hot, humid environment. It tends to occur
in those who have a febrile disease or who wear dressings,
casts, medical tape, or clothing that does not breathe.

Treatment Fig. 19.3 Pompholyx.

High temperature and humidity should be avoided. Careful Multiple vesicles on the palm.
washing of the body is necessary. When the eruptions are
eczematous, the treatments are the same as those for eczema. 19
Secondary infections should be carefully avoided.

2. Pompholyx
Synonym: Dyshidrosis

Pompholyx is a form of eczema of the palms and soles in

which edema fluid accumulates to form visible vesicles or Clinical images are available in hardcopy only.
bullae. Small blisters 1 mm to 5 mm in diameter occur multiply
on the palms and soles. The contents of the blister disappear in a
few days, resulting in scaling (Fig. 19.3). The blisters may
become eczematous and itchy in some cases; the condition is
called dyshidrotic eczema (Fig. 19.4).
Previously, pompholyx was thought to be a phenomenon caused
by sweat retention, because it most frequently occurs dur-ing the
summer, and hidrosis accompanies many cases. Never-theless, the
pathology is subcutaneous blistering accompanied by epidermal
spongiosis, which is not always associated with sweat Fig. 19.4 Dyshidrotic eczema.
 314 19 Disorders of the Skin Appendages

ducts or sweat glands. Further, the blister contents differ from

those of sweat.
Any exacerbating factors such as allergenic drugs should be
removed. Antiperspirant and keratolytic agents are used.
Steroids are applied topically on eczematous lesions.

3. Bromhidrosis
Synonym: Osmidrosis

Definition, Classification, Clinical features

Bromhidrosis (osmidrosis) is a general term for abnormal
body odor arising from sweat glands. Eccrine bromhidrosis and
apoc-rine bromhidrosis are the main types.
Eccrine bromhidrosis
Eccrine sweat may have a distinct odor, from intake of drugs
and foods such as garlic and spices. Bromhidrosis in feet is
caused by the bacterial action on keratin softened by sweat.
Apocrine bromhidrosis
Osmidrosis axillae, commonly called body odor, is the well-
known type. Bromhidrosis of the genitalia is also caused by
apocrine sweat. The sweat itself is odorless; however, fatty acids
are decomposed by superficial bacteria, resulting in the odor. The
apocrine glands begin to develop at puberty. Perspiration increas-es
with mental excitement and physical exercise.

Treatment
The skin should be kept clean to reduce bacterial flora and
apocrine sweat of the axilla. Application of antiperspirants,
deodorants or antibiotics, and shaving are effective. Systemic
antibiotics are most helpful. Laser, surgical or electrolysis depila-
tion may be performed as permanent cure. Reduction of eccrine
19 sweating using aluminum chloride may help decreases the local
bacterial flora, but will not reduce apocrine sweat production.
However, many patients who complain of offensive odor do not
actually have the odor; the complaints may represent paranoia
and phobia (osmidrophobia).

4. Fox-Fordyce disease
Synonym: Apocrine miliaria

Definition
Chronic, itchy papules occur, mainly on areas distributed with
apocrine sweat glands, such as the axillae and the pubic area.

Clinical features
The disease is uncommon and most of the reported cases have
occurred in young or middle-aged women. Follicular, solid, nor-
mal skin color or rose pink papules 2 mm to 3 mm in diameter
aggregate on the axillary fossae, areola of nipples, and genitalia.
 A. Disorders of the sweat glands 315

They are accompanied by intense itching.

Pathogenesis
When the sweat ducts of apocrine sweat glands are
obstructed, apocrine sweat exudes into the epidermis. The
pathogenesis of sweat gland obstruction is unknown; however,
there is possible involvement of hormones.

Treatment
The treatment of Fox-Fordyce disease is difficult. Laser
thera-py and topical application or local injection of steroids are
the first-line treatments. Clindamycin solution and tretinoin
cream are occasionally effective.

Prognosis
It is chronic and intractable.

5. Hyperhidrosis
Synonym: Hyperidorosis

Hyperhidrosis, caused by enhanced perspiration from the

eccrine glands, is classified into the subtypes described below.
Generalized hyperhidrosis
This occurs physiologically in hot, humid environments, dur-
ing exercise, or from sympathetic hypertonia. It also occurs in
patients with hyperthyroidism, diabetes, hypoglycemia,
dumping syndrome, gout, neurologic disease, spinal cord injury,
malignan-cies (especially, in Hodgkins disease), or other
primary disease, or it may be induced by drugs (e.g.,
antipyretics, anti-cholinesterase agents), pregnancy or obesity.
Localized hyperhidrosis Table 19.1 Diseases thought to cause
This occurs in the palms, soles, axillary fossae, face and else- 19
where. Most cases are from emotional perspiration. The condition anhidrosis.
is associated with constitutional factors and mental stress. Ion- Cause of Disease producing that cause
tophoresis using tap water is effective as a treatment in some cases. anhidrosis
Hyperhidrosis palmaris et plantaris may accompany atopic Congenital Hypohidrotic ectodermal dysplaisia
condition or palmoplantar keratosis. absence of
Hemihyperhidrosis is seen in patients with partial paralysis or sweat gland
function
Parkinsons disease. The hyperhidrosis occurs on one side of the
Metabolic Hypothyroidism, dehydration,
body from impairment of the peripheral nerves on that side. disorder thermic fever, Fabrys disease
Neurological Disorder of the hypothalamus and
6. Anhidrosis disorder spinal cord, alcoholic neuritis, lep-
rosy, diabetic neuropathy
Synonym: Hypohidrosis Obstruction Ichthyosis, seborrheic dermatitis,
of sweat atopic dermatitis, erythroderma,
pores and psoriasis
This is a condition with scant or absent perspiration. The skin is ducts
dry and coarse. Scaling and mild itching occur, and fever may be Atrophy or Scleroderma, systemic sclerosis,
produced by exercise because of lack of perspiration. Diseases damage of Sjgren syndrome, systemic lupus
suspected of causing anhidrosis are shown in Table 19.1. sweat erythematosus, solar elastosis, and
glands the like
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