Fox-Fordyce disease: A report of 2 cases responding to topical clindamycin

Anisha George, Anuradha Bhatia, Emy Thomas

 Department of Dermatology, Christian Medical College, Ludhiana, Punjab, India

Correspondence Address:
Anisha George
Department of Dermatology, Christian Medical College, Ludhiana - 141 008, Punjab
India

Sir,

A 15-year-old girl presented with a history of severely itchy persistent lesions under the arms and on the breasts for 2 years; and over the pubic region for 3 months. She was found to have faint erythematous to skin-colored, 2-3 mm sized, firm, smooth, dome-shaped, grouped, yet equidistant papules over the axillae, areolae [Figure - 1] and mons pubis. She also had decreased hair growth over the axillae and mons pubis. The surrounding skin was normal. A clinical diagnosis of Fox-Fordyce disease was made, and she was given topical clindamycin to be applied twice a day, with which, within 2 months she had remarkable improvement.

Figure 1: Skin colored papules over the left areola

The second patient was a 22-year-old lady, who presented with itchy lesions over the skin of the axilla for 6 years. Itching was worse in summers. She had no family history of similar disease. Cutaneous examination revealed skin-colored papules throughout the axillae with no terminal hair growth [Figure - 2]. She was initially treated with topical tretinoin, with no response; after which topical clindamycin twice daily was given, with which the lesions reduced.

Figure 2: Monomorphic papules over the right axilla with no terminal hair growth

Fox-Fordyce disease, also known as apocrine miliaria, is a rare condition seen in adolescent women, over the apocrine gland-bearing areas like the axillae, groin, areolae and inframammary creases in decreasing order of frequency. It is a chronic, treatment-resistant disorder with characteristic clinical features and non-specific histopathological features. The pathogenesis of this condition, initially thought to be due to hyperkeratosis, was subsequently shown to be caused by detached apo-eccrine secretory cells obstructing the intraepidermal apo-eccrine sweat ducts. ^[1] The only diagnostic feature, i.e., the "intraepidermal sweat retention vesicle" ^[2] is rarely seen. Clinical and differential diagnoses which can be considered include Graham-Little-Picardi-Lasseur syndrome and trichostasis spinulosa; however, our patients did not have cicatricial alopecia or lesions elsewhere on the body or mucosa. The lesions in trichostasis spinulosa are usually non-pruritic. Medical therapies reported to have been used in Fox- Fordyce disease are listed in the table [Table - 1]. The mechanism of action of clindamycin in this disease is unknown.

Lasers, including fractional CO2 laser, ^[13] have been used for recalcitrant lesions with a remarkable response in 3 months. However, lasers for axillary hair removal have been shown to induce Fox-Fordyce disease. ^[14] Surgical intervention is a definitive treatment and includes areolar dermal detachment safeguarding the nipple, apocrine sweat gland excision and fixation of the areola like a flap. ^[15]

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