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Axillary Fox-Fordyce Disease Treated With Liposuction-Assisted Curettage
K. Mireille Chae, MD;
Michael A. Marschall, MD;
Stephanie F. Marschall, MD
From the Department of Dermatology, Rush-Presbyterian-St Luke's Medical
Center (Drs Chae and Stephanie F. Marschall), and the Division of Plastic
Surgery, University of Illinois at Chicago (Dr Michael A. Marschall), Chicago,
Ill.
Arch Dermatol. 2002;138:452-454.
REPORT OF A CASE
A 33-year-old African American woman presented with a long history of
extremely pruritic, burning lesions in the axillae, on the breasts, and in
the inguinal area. The eruption first began at age 15 years, with flares following
pregnancy.
On physical examination, the patient was noted to have numerous discrete,
skin-colored papules in the axillae, around the areolae, and in the inguinal
area (Figure 1). Biopsy results
of one of these lesions were consistent with a diagnosis of Fox-Fordyce disease
or apocrine miliaria.
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Figure 1. Pruritic papules of Fox-Fordyce
disease in the axilla prior to liposuction-assisted curettage.
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Treatment with oral contraceptives was started with minimal improvement.
Oral antihistamines were ineffective in controlling the pruritus. Topical
0.025% tretinoin cream and clindamycin in propylene glycol solution, each
used separately, did not improve her symptoms and were discontinued due to
irritation. Topical corticosteroids helped to relieve the pruritus and the
burning sensation.
THERAPEUTIC CHALLENGE
Treatment of Fox-Fordyce disease is aimed at symptomatic relief and,
as in this patient, can be disappointing. Oral contraceptives, oral antihistamines,
topical tretinoin, and topical clindamycin were ineffective in controlling
the pruritus and decreasing the size and number of lesions in our patient.
Although topical corticosteroids helped to relieve the itch, prolonged continuous
use of corticosteroids in skin folds or occluded sites carries a high risk
of corticosteroid side effects. Surgical removal of the apocrine glands in
recalcitrant cases has been reported to relieve symptoms of pruritus and decrease
the number of papules 95% to 100%.1-2
SOLUTION
A modified form of liposuction was performed on one axillae. Under general
anesthesia, the right axilla was locally infiltrated with 0.5% bupivacaine
hydrochloride (Marcaine) and epinephrine (1:200 000). A small incision
was made along the axillary fold and a 4-mm suction lipectomy curet (Micrins)
was inserted, with the orifice of the curet placed adjacent to the dermis.
Suction was applied to the dermal surface and the curet was moved in a sweeping
fashion over the underside of the dermis throughout the region of involvement.
Less than 5 cm3 of material was extracted. An immediate decrease
in number of papules on the surface of the axilla could be seen during the
procedure. The insertion point was closed with interrupted 5-0 nylon suture.
A sterile dressing was applied to the insertion wound. The patient awakened
without difficulty, and was exubated and transferred to the recovery room
in stable condition. The patient went home the same day of the procedure.
Wound care consisted of daily dressing (Bandaid) change to the insertion
wound for 1 week. The postoperative period was uneventful. The patient had
no bruising following the procedure. Relief of pruritus in the axillae was
noted immediately following the surgery.
Two months following the procedure to the right axilla, the same procedure
was performed on the left axilla.
At 8 months after the second procedure, the patient had no pruritus
and very few papules in the axillae (Figure
2). The patient no longer required any topical corticosteroids to
the axillae, and the entry site scars from the procedures were barely visible.
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Figure 2. Eight months after liposuction-assisted
curettage.
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Liposuction was not performed in the groin and periareolar areas. The
patient continued to use intermittent topical corticosteroids for relief of
pruritus in these areas.
COMMENT
Fox-Fordyce disease is a rare, chronic, pruritic disorder characterized
by small perifollicular papules localized to the apocrine gland–bearing
regions of the skin. Although a century has passed since its first description
in 1902, the etiology and the exact pathogenesis of Fox-Fordyce disease remain
unknown. While its etiology and pathogenesis remain a mystery, it is clear
from the distribution of lesions and histologic findings that Fox-Fordyce
disease is a disorder of the apocrine glands.
Although several topical medications have been reported to be useful,
there is no definitive nonsurgical therapy for Fox-Fordyce disease. Numerous
treatments have appeared in the literature, including hot quartz UV lamp,3 oral isotretinoin,4
topical tretinoin cream,5-6 and
topical clindamycin solution.7-8
Our patient could not tolerate local irritation from topical tretinoin cream
or clindamycin solution.
Few descriptions of surgical therapy for Fox-Fordyce disease have been
published. The traditional surgical removal of apocrine glands is an extensive
surgery. For the axillae, one approach is to excise the affected region of
the axilla.1 For breast areola, a surgical
technique has been described that involves dermal detachment of the areola,
then excision of the underlying apocrine sweat glands, and finally placement
of the previously detached areola as a skin graft.2
Recently, liposuction has been found to be beneficial in the treatment
of axillary hyperhidrosis. Permanent removal of sweat glands can be achieved
through a modified liposuction technique in which a liposuction cannula is
introduced through a stab incision in the axilla and, with the aperture of
the cannula turned up toward the underside of the dermis, the deeper dermis
is curetted to create inflammation and subsequent fibrosis.9-10
An additional variation to this procedure is the use of tumescent regional
anesthesia.11-12
As it is with axillary hyperhidrosis, eradication of the causal glands
is the underlying principle in the use of this technique in our patient with
Fox-Fordyce disease. The apocrine gland is composed of 3 segments: the intraepithelial
duct, the intradermal duct, and the secretory portion. The apocrine gland's
coiled secretory portion is located at the junction of the dermis and subcutaneous
fat. Eccrine glands have their coiled secretory portion within the panniculus
near the junction of the dermis and subcutaneous fat. It has been argued that
liposuction would not work well for apocrine diseases because of the attachment
of the coiled secretory portion of the apocrine glands to the lower portion
of the dermis, in contrast to eccrine glands, which have their coiled secretory
portion in the fat.13 Successful treatment
of axillary bromhidrosis has been reported, however, with additional findings
of apocrine glands and eccrine glands within the aspirate.14
The combination of the suction and the mechanical scraping of the underside
of the dermis likely facilitates the removal of the apocrine glands. The consequent
inflammation and fibrosis of the underside of the dermis may also contribute
to the overall effect of the liposuction curettage in eradicating the apocrine
glands.
Liposuction-assisted curettage was clearly beneficial in our patient.
While suction-assisted curettage using liposuction cannulas may not be appropriate
for all patients and for all areas of disease involvement, we recommend its
consideration for recalcitrant Fox-Fordyce disease of the axillae.
AUTHOR INFORMATION
Accepted for publication August 2, 2001.
Corresponding author: Stephanie Marschall, MD, Department of Dermatology,
Rush-Presbyterian-St Luke's Medical Center, 1653 W Congress Pkwy, Chicago,
IL 60612-3864.
REFERENCES
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5. Giacobetti R, Caro WA, Roenigk HH. Fox-Fordyce disease: control with tretinoin cream. Arch Dermatol. 1979;115:1365-1366.
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9. Coleman WP. Noncosmetic applications of liposuction. J Dermatol Surg Oncol. 1988;14:1085-1090.
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bei hyperhidrosis axillaris. [Subcutaneous sweat gland suction curettage in
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12. Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starch-iodine
test with the tumescent liposuction technique. Dermatol Surg. 2000;26:392-396.
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13. Park DH. Treatment of axillary bromhidrosis with superficial liposuction [letter]. Plast Reconstr Surg. 1999;104:1580-1581.
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SECTION EDITOR: GEORGE J. HRUZA, MD; ASSISTANT SECTION EDITORS: DEE
ANNA GLASER, MD; ELAINE SIEGFRIED, MD
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