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Table of Contents
Year : 2021  |  Volume : 39  |  Issue : 3  |  Page : 165-166

Yellow vesicular palmar eruption in a young man with hyperbilirubinemia: Eccrine chromhidrosis

Department of Dermatology, China Medical University Hospital, Taichung City, Taiwan

Date of Submission28-Jan-2021
Date of Decision05-Mar-2021
Date of Acceptance30-Mar-2021
Date of Web Publication19-Jul-2021

Correspondence Address:
Dr. Ya-Hui Hsieh
No 2, Yude Road, North District, Taichung City 404332
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.ds_21_21

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How to cite this article:
Hsieh YH. Yellow vesicular palmar eruption in a young man with hyperbilirubinemia: Eccrine chromhidrosis. Dermatol Sin 2021;39:165-6

How to cite this URL:
Hsieh YH. Yellow vesicular palmar eruption in a young man with hyperbilirubinemia: Eccrine chromhidrosis. Dermatol Sin [serial online] 2021 [cited 2022 Dec 5];39:165-6. Available from: https://www.dermsinica.org/text.asp?2021/39/3/165/321877

Dear Editor,

Eccrine chromhidrosis secondary to hyperbilirubinemia is a rare condition. The eruption is clinically characterized by yellow–green vesicles on palmoplantar skin. We report a case of eccrine chromhidrosis secondary to acute cholecystitis-induced hyperbilirubinemia diagnosed by capillary tube test.

A 25-year-old man without systemic diseases had a yellow vesicular eruption on palms for 4 days, accompanied by high fever and abdominal pain. He was diagnosed with acute cholecystitis with obstructive jaundice after series studies. Physical examination found multiple asymptomatic yellowish pompholyx-like vesicles on palms and fingers. There was no discoloration on other body location, and his sweat was colorless. He denied a history of contact yellowish material, and he denied carotene-rich food overconsumption. The vesicles became greenish during the hospital course [Figure 1]. Laboratory tests showed elevated total bilirubin (9.7 mg/dl), direct bilirubin (5.9 mg/dl), aspartate aminotransferase (45 IU/L), alanine aminotransferase (118 IU/L), alkaline phosphatase (129 IU/L), and r-glutamyl transferase (129 IU/L). He refused skin biopsy. We therefore used capillary tube sampling for the vesicles, and microbilirubin was detected in the fluid (2.5 mg/dL). Eccrine chromhidrosis secondary to hyperbilirubinemia was diagnosed accordingly. The symptoms improved after endoscopic retrograde cholangiography and pancreatography, and the vesicles resolved with desquamation 2 weeks later.
Figure 1: (a) Asymptomatic yellowish pompholyx-like vesicles on the patient's palms and fingers. (b) Few days later, the lesions gradually turned to green.

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Eccrine chromhidrosis is a rare condition, which occurs when water-soluble pigments are excreted from the eccrine glands after the ingestion of certain dyes or drugs.[1],[2] Eccrine chromhidrosis secondary to hyperbilirubinemia is rarer. Kanzaki and Tsuda[3] first described two cases of bile pigment deposition at sweat pores of patients with liver disease. To the best of our knowledge, it has been published in only ten patients [Table 1]. According to previous reports, the causes of hyperbilirubinemia include hepatitis, cirrhosis, hepatobiliary malignancy, and cholelithiasis. Age at presentation ranged from 16 to 76 years. Interestingly, including our patient, all cases are male. The total-bilirubin level ranged from 17 to 54 mg/dl, and the direct-bilirubin level ranged from 7.97 to 31.6 mg/dl. The affecting area was almost confined to acral skin. Mild pruritus may present, but mostly it is asymptomatic. The cutaneous lesions resolve spontaneously in 1 to 8 weeks.
Table 1: Summary of reported cases with eccrine chromhidrosis

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Kanzaki and Tsuda[3] proposed three essential factors for developing eccrine chromhidrosis: (1) increase serum level of direct bilirubin, (2) high fever with sweating, and (3) the thicker horny layer. It is hypothesized that when febrile events occur and sweating increases in the patients with hyperbilirubinemia, the excretion of the bilirubin from eccrine glands also increases. The highest eccrine gland density and thicker horny layer of acral skin contribute to more prominent bilirubin deposition in the palmoplantar area and thus the golden-yellow eruption. As bilirubin naturally oxidizes to biliverdin, the lesions turn green. Due to the rarity of the disease, there is no statistical analysis for correlating the severity and serum bilirubin level. Our case exhibited a similar disease course to the reports but comparatively lower bilirubin level [Table 1]. We presume that not only bilirubinemia but also other contributing factors, such as fever, sweat producing, and skin thickness would exacerbate this condition.

The classical yellow–green discoloration on acral skin with concomitant liver dysfunction yields the suspicion of eccrine chromhidrosis. Dermoscopy offers additional diagnostic value. Brown or green pigments distributed along the dermatoglyphic ridges where the eccrine gland open is consistently present in former literatures.[2],[4],[5] In the cases that the skin biopsy was performed, the histopathology findings include hyperkeratosis, amorphous substance within the stratum corneum and in dilated adnexal pores, and inflammatory spongiotic vesicles.[2],[4],[5],[6],[7] Two cases demonstrated positive bilirubin stain by Hall stain and Fouchet stain.[2],[4],[8] In our case, we performed a capillary tube test. The capillary tube test, which refers to sampling by a capillary tube, is commonly used in neonatal jaundice. By making a puncture and then placing the capillary tube, the blood is drawn up the tube spontaneously due to the capillary effect. The microbilirubin level of specimen is analyzed by bilirubinometer in the laboratory. This method takes advantages of only tiny punctures and small volumes of sample required, and thus, it is applicable in our case. Since we sampled vesicular fluid instead of blood, the value of microbilirubin level may not represent true serum bilirubin level, but it still supports the diagnosis when detecting bilirubin in lesional skin. This finding is compatible with Kanzaki's hypothesis that excessive bilirubin excretion from sweat glands and bilirubin deposition into the skin result in this condition.

In summary, we report a case of eccrine chromhidrosis secondary to hyperbilirubinemia. We proposed that eccrine chromhidrosis should be considered a sign of liver dysfunction and the capillary tube test may serve as an easy, noninvasive method for making the diagnosis.

Declaration of patient consent

The author certifies that she has obtained appropriate patient consent form. In the form, the patient has given his consent for the images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ghosh SK, Bandyopadhyay D. The color of skin: Green diseases of the skin, nails, and mucosa. Clin Dermatol 2019;37:516-9.  Back to cited text no. 1
Triwongwaranat D, Kasemsarn P, Boonchai W. Green pigmentation on the palms and soles. Acral green pigmentation (eccrine chromhidrosis). JAMA Dermatol 2013;149:1339-40.  Back to cited text no. 2
Kanzaki T, Tsuda J. Bile pigment deposition at sweat pores of patients with liver disease. J Am Acad Dermatol 1992;26:655-6.  Back to cited text no. 3
Di Stefani A, Bianchi L, Orlandi A, Chimenti S. Green sweating spots on hands and feet: Unusual expression of hyperbilirubinemia. Ann Intern Med 2006;145:710-1.  Back to cited text no. 4
Park JG, Prose NS, Garza R. Eccrine Chromhidrosis in an Adolescent with Sickle Cell Disease. Pediatr Dermatol 2017;34:e273-4.  Back to cited text no. 5
Uzoma M, Singh G, Kohen L. Green palmoplantar vesicular eruption in a patient with hyperbilirubinemia. JAAD Case Rep 2017;3:273-5.  Back to cited text no. 6
Keum DI, Hong H, Lee SH, Ahn SK. Eccrine chromhidrosis resembling clinical features of pompholyx with bile-like greenish pigmentation on the right palm and soles. Ann Dermatol 2015;27:482-3.  Back to cited text no. 7
Allegue F, Hermo JA, Fachal C, Alfonsín N. Localized green pigmentation in a patient with hyperbilirubinemia. J Am Acad Dermatol 1996;35:108-9.  Back to cited text no. 8


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