What is the appropriate workup and treatment for a patient presenting with bromhidrosis (body odor)?

Bromhidrosis Workup and Management

Initial Clinical Assessment

Begin with focused history targeting the specific characteristics of body odor: location (axillary vs. generalized), onset, duration, severity, impact on social/occupational function, family history, and current hygiene practices. 1

Key History Elements

• Distinguish focal from generalized bromhidrosis through detailed questioning about odor distribution—axillary bromhidrosis is most common and typically apocrine-related, while generalized forms may indicate systemic disease 1
• Assess for secondary causes including medications, dietary factors (garlic, curry, alcohol), metabolic disorders (trimethylaminuria, diabetes), and hyperhidrosis as a contributing factor 1
• Quantify psychosocial impact using patient-reported severity scales to guide treatment intensity 2

Physical Examination Specifics

• Inspect axillae for apocrine gland distribution within hair-bearing areas, noting extent and density 3
• Evaluate for concurrent hyperhidrosis using starch-iodine test or direct observation of sweating patterns 1
• Examine for skin changes including maceration, secondary infections, or dermatitis that may contribute to odor 1
• Assess for signs of systemic disease if generalized bromhidrosis is present (thyroid enlargement, neurological findings) 1

Diagnostic Workup

No laboratory testing is required for typical focal axillary bromhidrosis, as this is a clinical diagnosis based on history and physical examination alone. 1, 3

When to Investigate Further

• Order thyroid function tests, fasting glucose, and complete metabolic panel only if generalized hyperhidrosis or systemic symptoms suggest secondary causes 1
• Consider bacterial culture only if secondary infection is suspected or if standard treatments fail 3
• Genetic testing for trimethylaminuria should be reserved for cases with fish-like odor unresponsive to standard management 1

Treatment Algorithm

First-Line Conservative Management (All Patients Initially)

Start with topical antiperspirants containing aluminum chloride hexahydrate 20% applied nightly to dry skin, combined with antibacterial soaps (chlorhexidine or triclosan) and fragrance products. 1, 3

• Aluminum-based antiperspirants reduce apocrine secretions and create an unfavorable environment for bacterial colonization 1
• Antibacterial agents target the bacterial degradation of apocrine secretions that produces malodor 3
• Counsel patients that conservative measures provide temporary relief only and require ongoing daily use 3

Second-Line Options for Inadequate Response

If topical measures fail after 4-6 weeks, consider botulinum toxin A injections (50-100 units per axilla) or iontophoresis for concurrent hyperhidrosis. 1

• Botulinum toxin reduces both eccrine and apocrine secretions but requires repeat treatments every 6-12 months 1
• Iontophoresis is effective for hyperhidrosis but has limited direct effect on bromhidrosis 1
• Systemic anticholinergics (glycopyrrolate, oxybutynin) may help if generalized hyperhidrosis contributes, but side effects limit use 1

Definitive Surgical Management

For patients with severe, refractory bromhidrosis causing significant psychosocial impairment despite conservative measures, surgical excision of apocrine glands via mini-incision with subdermal vascular preservation achieves 85-87% very satisfactory results at 2 years. 4, 5

Surgical Technique Selection

• Mini-incision with subdermal vascular preservation is the preferred approach, balancing efficacy (87.1% very satisfactory results) with lower complication rates compared to traditional wide excision 4
• Subcutaneous scissor with micropore technique offers 85% excellent results with minimal scarring through single small incision and meticulous gland excision under direct visualization 5
• Microwave-based therapy represents emerging option with high patient satisfaction and transient adverse effects, achieving 2-point drop in malodor grading at 12 months 2

Critical Surgical Principles

• Thorough apocrine gland clearance throughout the entire hair-bearing area is essential to prevent malodor recurrence 4
• Preserve subdermal vascular plexus to support skin flap survival and minimize necrosis, scarring, and other severe complications 4
• Apply bulky compressive dressings for 72 hours postoperatively to prevent hematoma formation 5

Common Pitfalls to Avoid

• Do not perform liposuction alone for bromhidrosis—while it removes some apocrine glands, incomplete clearance leads to high recurrence rates 3
• Avoid systemic antibiotics as routine treatment since bacterial colonization recurs immediately after discontinuation 3
• Do not recommend surgery without documented failure of conservative measures for at least 3 months 1
• Counsel patients preoperatively about realistic expectations: 10-15% may have residual mild odor or cosmetic concerns (scars, skin irregularities, epidermoid cysts) 4

Expected Complications by Treatment Modality

Short-term surgical complications include hematomas, epidermal erosions, infections, necrosis, and incision dehiscence occurring in approximately 10-15% of cases 4

Long-term surgical complications include comedones, epidermoid cysts, recurrent cyst infections, skin irregularities, scars, keloids, and persistent mild malodor in 10-13% of patients 4