Bromhidrosis: The Not So Sweet Smell Of Summer
By Larisa M. Lehmer, MD, MA
It’s summertime and the hot weather means a chance to enjoy lemonade, the beach, and backyard barbecues. Soaking in the balmy atmosphere of the longer days relaxing with friends is pure fun until the inevitable trickle down the spine or Velcro-like armpit stickiness develops. Yes, I’m talking sweat, the bane of the season. For most, increased perspiration is a mere nuisance, but for others it is accompanied by an unwelcome foul odor. The distress and embarrassment can be so overwhelming that those who suffer from “bromhidrosis,” from the Greek bromos meaning buck’s stench, and hidros for “water” or “sweat,” feel compelled to avoid social settings entirely. Bans on excessive body odor in many California libraries to Swiss government buildings and Chinese spaceships, bromhidrosis may impinge on the rights of the individual to pursue education and employment in an effort to protect the nostrils of society from onerous assault.
What is bromhidrosis?
The sour, musty smell of bromhidrosis is often mistaken for a lack of personal hygiene. In fact, individuals with bromhidrosis shower just as frequently, if not more so, than the rest of us. Instead, the smell comes from the breakdown of odor-free substances in sweat into noxious compounds including ammonia, butyric, and formic acids by bacteria naturally present on the skin. Although species like Propionobacterium acnes contribute to the ubiquitous dermatologic disease of acne, and pathologic strains of Staphylococcus aureus may cause infection, current research suggests that the “skin microbiome,” plays a very important role in maintaining the integrity and function of our skin. Each region of the skin has it’s own bacterial ecosystem and, like a fingerprint, no two people have the same microbial profile. Many factors including gender (men and women produce different types of sweat), genetics, surrounding temperature/humidity, and diet contribute to the presence of one or another type of bacteria. Recent genetic analysis has identified the dominant “wet earwax gene” (ABCC11) in the DNA of individuals with bromhidrosis, which suggests strong body odor could be inherited.
Before jumping to a diagnosis of bromhidrosis, there are other causes of bad body odor that should be considered first because these are easier to fix. A yeast infection of the top layer of the skin, particularly in areas that remain damp such as the groin, armpit, and in-between skin folds can be treated with a topical antifungal cream and prevented by regular cleansing and drying of the affected areas. Regular shaving may eliminate odor emanating from the armpits and groin if the culprit is trichomycosis axillaris (a corynebacterial infection of the hair shafts). Uncontrolled diabetes mellitus can lead to bad body odor, which tends to have a “fruity” smell, and maintaining blood sugars within a normal range resolves this issue as well as the many other dangerous effects of the disease. Something as simple as wearing certain types of fabric can lead to unpleasant smells and opting for natural, breathable materials, which allow for better ventilation may be the solution. Finally, a trial of eliminating certain foods and substances such as garlic, onions, alcohol, hot spices, caffeine, and nicotine may also prove effective.
If diet, clothing, and simple hygiene adjustments fail, consultation with a dermatologist is advised.
Treatment generally starts with prescription topical antibiotics which act to limit the growth of unwanted bacteria. Drying agents including prescription-strength aluminum chloride are employed if bromhidrosis is associated with excessive sweating, or hyperhidrosis. Medications in the anticholinergic class decrease the production of sweat, but are rarely used due to their side effects.
Patients seeking a more long-term solution may opt for treatment with lasers or botulinum toxin A, a.k.a. Botox®. The laser works by destroying the sweat glands beneath the surface of the skin with 75% of 1,444 patients reporting satisfaction with their results 6 months later. Injecting the armpits or groin with botulinum toxin A disrupts the nerves to the sweat glands and is already used for hyperhidrosis.
If all else fails, surgery can be performed to remove the sweat glands entirely. This option is much more popular amongst many Asian populations where the slightest body odor is frowned upon and therefore a cause of much greater psychological distress. Procedures range from minimally invasive superficial liposuction, which has the benefit of less scarring but a higher rate of recurrent odor, to removing all the skin and underlying tissue of the affected area such as the entire surface of the armpits. While the latter essentially guarantees banishment of the offending odor, it carries the risk of significant scarring.
Smell, the underappreciated sense
If the question were asked, “Which sense would you miss the least: sight, hearing, taste, touch, or smell?” an individual from a Western or Asian culture, and perhaps anyone having just read this article highlighting unsavory aromas, is most likely to opt to give up smell. In contrast, the Ongee of the Andaman Islands regard smell as the “emperor of the senses” best illustrated by the common greeting of “How is your nose?” the polite response to which is, “Heavy with odor” (in lieu of, “How are you?” and, “Fine”). While the importance of smell varies between societies the fact of the matter is that it does have a significant impact on how human beings suffering from the unusually bad body odor of bromhidrosis are treated. Subconscious associations between an unpleasant body odor and the uncleanliness, or lower socio-economic standing of the individual are formidable prejudices to overcome. Increased social and medical awareness are needed to help individuals with bromhidrosis find the support and treatment they need.