/ /

  • linkedin
  • Increase Font
  • Sharebar

    Nervous teenager’s hands turn blue


    Diagnosis: pseudochromhidrosis

    Pseudochromhidrosis is a rare condition wherein sweat interacts with various nonpathologic bacteria on the skin, usually the chromogenic Corynebacterium, and this chemical reaction causes blue or sometimes black or red discoloration in patchy areas on the skin. It also can result from the reaction between the sweat and other pathogens such as Bacillus species and certain fungi (Piedraria), dyes, drugs (Rifampin), and other chemicals (copper).7 Wiping the skin with an alcohol pad usually makes the diagnosis.

    Pseudochromhidrosis has to be differentiated from chromhidrosis (Greek for “colored sweat”), which is an even more unusual condition characterized by the secretion of colored sweat, because it has several more ominous causes. There are 2 forms of chromhidrosis, dependent on the origin of the colored sweat from apocrine or eccrine glands.

    Apocrine chromhidrosis is usually facial, but can occur wherever apocrine glands are present, including the nipples, axilla, and anal areas. Yellowish brown lipofuscin pigment is responsible for the colored sweat when there is a higher oxidative stress in the apocrine glands. This condition is usually idiopathic, and the color of the sweat depends on the oxidation of the lipofuscin, including yellow, blue, brown, green, or black. Diagnosis can be made by performing a skin biopsy looking at the presence of lipofuscin granules or autofluorescence of sweat, skin specimens, or clothing under a Wood lamp.

    In contrast, eccrine chromhidrosis occurs with ingestion of certain dyes or drugs, some deadly. Dyes such as bromophenol blue, which is used as an acid-base indicator or dye, can be fatal with ingestion. The ingestion of copper salts, used as a fungicidic agent, also can cause discoloration of the skin, but now is considered too toxic. However, copper salts are found in children’s chemistry sets and used to grow crystals. Identification of copper salts via thorough patient history can determine if ingestion has occurred.


    The distinction between pseudochromhidrosis and apocrine or eccrine chromhidrosis is vitally important for treatment and prognosis.

    Pseudochromhidrosis usually responds to treatments that eliminate the bacteria on the skin, such as chlorhexidine scrubs, topical antibiotics, and, rarely, oral antibiotics.

    There is no known treatment for the accumulation of lipofuscin, so in apocrine chromhidrosis the treatment is geared toward decreasing sweat using 20% aluminum chloride hexahydrate (Drysol), topical capsaicin (a topical cream made from hot peppers), or injections of botulism toxin (Botox). Definitive treatment of chromhidrosis is surgical excision of the affected apocrine sweat glands.8-14

    Treatment of eccrine chromhidrosis consists of identifying and eliminating the ingestion of the soluble pigment.

    Back to the case

    The patient in this case was the daughter of author Daniel Taylor, MD. The night of the ED visit, he received an e-mail from his coauthor Dana Toib, MD, who is a pediatric rheumatologist, with the subject line “green fingers.” The fingers discoloration spared the palms and interdigital space, making vasospasm, vascular occlusion, hypoxemia, and methemoglobinemia unlikely. This raised the suspicion that the blue discoloration of the girl’s hands was a result of skin discoloration, in particular, pseudochromhidrosis. The e-mail included a description of pseudochromhidrosis and how to diagnose it using a wet alcohol pad.

    Next: Delayed menarche with normal pubertal growth

    It was late at night, so Dr. Taylor waited until sunrise, cloth soaked with alcohol in hand, to wake his daughter. “What are you doing?” she asked him as he hovered over her bed. “Trust me,” he said as he wiped the cloth hard across her knuckles. The color that had mystified his daughter, her school, and the ED physician transferred easily onto the cloth, and he continued to wipe away the blue coloration from her hands until it all was removed. He cancelled her specialist appointments, thanked his coauthor for her e-mail, and bought some antibacterial hand wipes in preparation for his daughter’s next oral presentation.


    1. Wigley FM, Flavahan NA. Raynaud’s phenomenon. N Engl J Med. 2016;375:556-565.

    2. Wigley FM. Clinical practice. Raynaud’s phenomenon. N Engl J Med. 2002;347(13):1001-1008

    3. Das S, Maiti A. Acrocyanosis: an overview. Indian J Dermatol. 2013;58(8):417-420.

    4. Syed RH, Moore TL. Methylphenidate and dextroamphetamine-induced peripheral vasculopathy. J Clin Rheumatol. 2008;14(1):30-33.

    5. Bennett DL, Woods CG. Painful and painless channelopathies. Lancet Neurol. 2014;13(6):587-599.

    6. Cilliers J, de Beer C. The case of the red lingerie—chromhidrosis revisited. Dermatology. 1999;199(2):149-152.

    7. Rodriguez-Martin M, Rodriguez MS, Cabrera AN. Palmar and digital black pseudochromhidrosis: a case report. Int J Dermatol. 2010;49(5):562-564.

    8. Koley S, Mandal RK. Red and black pseudochromhidrosis. Indian J Dermatol. 2016;61(4):454-457.

    9. Panagoulias GS, Basagiannis CS, Tentolouris N, Stavropoulou E, Karnesis L. Colored sweat caused by pseudochromhidrosis. Ann Intern Med. 2010;152(3):198-199.

    10. Griffith JR. Isolated areolar apocrine chromhidrosis. Pediatrics. 2005;115(2):e239-e241.

    11. Wang A, Wysong A, Nord KM, Egbert BM, Kosek J. Chromhidrosis: a rare diagnosis requiring clinicopathologic correlation. Am J Dermatopathol. 2014;36(10):853-855.

    12. Thami GP, Kanwar AJ. Red facial pseudochromhidrosis. Br J Dermatol. 2000;142(6):1219-1220.

    13. Harada K, Morohoshi T, Ikeda T, Shimada S. A patient with pseudochromhidrosis presenting with pink nails. J Am Acad Dermatol. 2012;67(2):e74-e75.

    14. Burggraaff JEC, Linthorst GE, Hoogerwerf JJ. Transient blue skin: pseudochromhidrosis. EJCRIM. 2014;1:doi: 10.12890/2014_000084.

    Daniel R Taylor, DO, FAAP, FACOP
    Dr Taylor is associate professor of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania, and attending ...
    Dana Toib, MD
    Dr Toib is assistant professor, Drexel University College of Medicine, Philadelphia, and attending physician, General Pediatrics and ...

    1 Comment

    You must be signed in to leave a comment. Registering is fast and free!

    All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

    • Anonymous
      Not an uncommon finding in schools at all....think new blue jeans at the beginning of school, or after Christmas holidays. A good school nurse will have a student wash their hands as part of a rule out in this situation, as well as our usual exam.


    Latest Tweets Follow