THE CUTTING EDGE

THE CUTTING EDGE
SECTION EDITOR: GEORGE J. HRUZA, MD;
ASSISTANT SECTION EDITORS: DEE ANNA GLASER, MD; ELAINE SIEGFRIED, MD
Axillary Fox-Fordyce Disease
Treated With Liposuction-Assisted Curettage
K. Mireille Chae, MD; Michael A. Marschall, MD; Stephanie F. Marschall, MD; 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
The Cutting Edge: Challenges in Medical and Surgical Therapeutics
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.
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 suc(REPRINTED) ARCH DERMATOL / VOL 138, APR 2002
452
Figure 1. Pruritic papules of Fox-Fordyce disease in the axilla prior to
liposuction-assisted curettage.
tion 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 apWWW.ARCHDERMATOL.COM
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plied 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.
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 FoxFordyce disease remain unknown. While its etiology and
pathogenesis remain a mystery, it is clear from the distribution of lesions and histologic findings that FoxFordyce 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 FoxFordyce 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 intraepi(REPRINTED) ARCH DERMATOL / VOL 138, APR 2002
453
Figure 2. Eight months after liposuction-assisted curettage.
thelial 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.
Accepted for publication August 2, 2001.
Corresponding author: Stephanie Marschall, MD,
Department of Dermatology, Rush-Presbyterian-St Luke’s
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REFERENCES
1. Storino WD, Engel GH. Office surgical management of recalcitrant axillary lesions. Cutis. 1978;21:338-341.
2. Chavoin JP, Charasson T, Bernard JD. Traitement chirurgical de l’hidrosade´nite et
de la maladie de Fox-Fordyce are´olaires. Ann Chir Plast Esthet. 1994;39:233-238.
3. Pinkus H. Treatment of Fox-Fordyce disease [letter]. JAMA. 1973;223:924.
4. Effendy I, Ossowski B, Happle R. Fox-Fordyce disease in a male patient: response to oral retinoid treatment. Clin Exp Dermatol. 1994;19:67-69.
5. Giacobetti R, Caro WA, Roenigk HH. Fox-Fordyce disease: control with tretinoin
cream. Arch Dermatol. 1979;115:1365-1366.
6. Tkach JR. Tretinoin treatment of Fox-Fordyce disease [letter]. Arch Dermatol.
1979;115:1285.
7. Feldman R, Masouye´ I, Chavaz P, Saurat JH. Fox-Fordyce disease: successful
treatment with topical clindamycin in alcoholic propylene glycol solution. Dermatology. 1992;184:310-313.
8. Miller ML, Harford RR, Yeager JK. Fox-Fordyce disease treated with topical clindamycin solution. Arch Dermatol. 1995;131:1112-1113.
9. Coleman WP. Noncosmetic applications of liposuction. J Dermatol Surg Oncol.
1988;14:1085-1090.
10. Payne CM, Doe PT. Liposuction for axillary hyperhidrosis. Clin Exp Dermatol.
1998;23:9-10.
11. Hasche E, Hagedorn M, Sattler G. Die subkutane schwei␤dru¨sensaugku¨rettage
in tumeszenzlokalana¨sthesis bei hyperhidrosis axillaris. [Subcutaneous sweat gland
suction curettage in tumescent local anesthesia in hyperhidrosis axillaris]. Hautarzt. 1997;48:817-819.
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12. Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starchiodine test with the tumescent liposuction technique. Dermatol Surg. 2000;26:
392-396.
13. Park DH. Treatment of axillary bromhidrosis with superficial liposuction [letter].
Plast Reconstr Surg. 1998;104:1580-1581.
14. Ou LF, Yah RS, Chen IC, Tang YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg. 1998;102:1479-1485.
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