Comparasion Of The Efficacy Of Four Different Surgical Strategies For Axillary Osmidrosis And Exploration Of The Role Of Apod In The Treatment Of Axillary Osmidrosis Patients

Axillary Osmidrosis (AO) is a common disease which most frequently occurs in young adults. It is generally considered that axillary osmidrosis is related to the abnormal secretions of the apocrine sweat gland and has strong genealogical links. In China, AO has a powerful negative psychological influence on patients, leading to a high demand for therapy. Currently, there are four surgical therapeutic methods in use when dealing with axillary osmidrosis in our department: electro-acupuncture therapy; axillary skin resection and Z-remodeling operation; suction and curettage with tumescent anaesthesia; intermediate-thickness skin grafting. Each procedure is replete with its own particular advantages and disadvantages. In this study, we systematically compare the efficacy of the four different therapeutic strategies. For a full understanding of the mechanism through which AO occurs, we must begin by exploring the genesis of ApoD; from its essence in E-3M2H secretion, which is so often characterized by its symptomatic unpleasant odor. Aim:To compare the efficacy of the four different therapeutic strategies used in our hospital. To compare the differences in the physical symptoms of patients with ApoD in axillary osmidrosis and normal subjects. To explore the underlying mechanism, especially the role of JNK1, in the process through which AO occurs.Methods:1) 109 axillary osmidrosis patients, recruited from 2006.9 until 2010.9, were divided into four groups. Patients from each these four groups all underwent a different type of curative procedure; electro-acupuncture therapy, axillary skin resection and Z-remodeling operation, suction and curettage with small skin incision and Local anesthesia, and inter-mediate thickness skin graft respectively. The efficacy and complications associated with each type of therapy were then systematically evaluated and compared.2) Biopsy specimens of the underarm area were obtained from healthy male donors (n =4) and axillary osmidrosis patients (n = 10) following local anesthesia with lidocaine hydrochloride [containing epinephrine hydrochloride at a dilution of 1:100 000]. We compared the expression of ApoD between the normal and osmidrosis subjects through; Western Blot, immunohistochemistry and qRT-PCR. The activation of JNK1 was also studied to explore the potential for involvement of JNK1 and AR signaling in ApoD regulation.3) Seventy-eight axillary osmidrosis patients were recruited from our department from 2008.10-2010.12 in Tangdu Hospital. Patients were classified into three groups according to the extent of the osmidrosis. Briefly, the osmidrosis patients were asked to stay in a room (with a constant temperature of 28°C and with the door closed) and to keep their arms naked and exposed. The same examiner was asked to smell the unpleasant odor from each of the different test patients sequentially: from 5, 3 and 1 meter's distance. The extent of the osmidrosis was classified into a basic scale of; mild, middle and severe odor, and corresponded to the unpleasantness of the odor detected. Biopsy specimens of the underarm area were also obtained from axillary osmidrosis patients following local anesthesia with lidocaine hydrochloride [containing epinephrine hydrochloride at a dilution of 1:100 000]. For RNA analysis, intact skin from was rinsed with D-Hank buffer, and subcutaneous fat was removed. The skin was minced (1mm3) with sharp scissors in a culture plate. The pieces were then incubated with type II collagenase (3 mL) at 37°C in a humidified atmosphere of 5% CO2 and 95% air. On the following day, the gland coils were removed and harvested for RNA isolation. Tissue samples were rinsed twice in cold sterile PBS, and total RNA was extracted by Trizol (Invitrogen) following the manufacturer's instructions. Total RNA was quantified and 1μg RNA was reverse transcribed by M-MLV. qPCR was performed using an AB 7500 Real-Time PCR System. Each sample was run in triplicate for both genes of interest and the housekeeping gene.Results:1) The general efficacy of the four surgeries was 94%. The therapeutic effect of electro-acupuncture therapy was much lower than the other three. This procedure also resulted in some recurrence of the symptoms. Axillary skin resection with Z-remodeling operation and inter-mediate thickness skin graft cured the disease. The success ratio of suction and curettage with tumescent anaesthesia was around 80%,with some patients having some remaining unpleasant odor or later recurrence. All four surgeries had certain complications and side effects.2) The relative expression levels of ApoD in axillary osmidrosis patients are nearly 2 times higher than that found in the normal control sample. Consistently, ApoD expression at protein level was also higher in osmidrosis patients than that in the normal subjects. In addition, AR expression was also found to be higher in axillary osmidrosis subjects. Accordingly, phosphorylated JNK was also higher but there was no significant difference of the absolute level between the two groups.3) Apocrine gland cells from the axillary osmidrosis subjects were cultured in vitro. Activation of JNK1 and high expression of ApoD continued even after 10 days of culture generation. JNK1 inhibitor SP600125 significantly blocked the activation of JNK1. Accordingly, ApoD decreased both at protein level and mRNA level. In contrast, in vitro cultured apocrine cells expressing low level of ApoD from the normal subject were stimulated with 5α-dihydrotestosterone at concentration levels of 10-7M and 10-6M. When the drug concentration was increased, ApoD expression enhanced gradually. Whilst blocking JNK activation with SP600125, increased ApoD was seen to be compromised both at protein and mRNA level.4) We analyzed a total of 78 individuals with axillary osmidrosis. There were 12"mild", 24"middle"and 42"severe"patients. Of the 78 axillary osmidrosis patients, 29 were females and 49 were males. Therefore, more males were in the severe axillary osmidrosis category. Next we tested the expression of ApoD at mRNA level among these 78 patients by real-time assay. The expression of ApoD differed among these subjects. The highest level was nearly 6 times higher than that of the lowest level. It seems that expression of ApoD in severe axillary osmidrosis patients is much higher than that in mild patients.Conclusion:1) All of the four different surgeries have advantages and disadvantages. Though the therapeutic effect of electro-acupuncture therapy was the lowest, it causes less invasive lesion and the operation fee is much cheaper. Selection of the surgery should be based upon the severity of the axillary osmidrosis, the effect on the will of the patients and so on.2) Our study here demonstrates that the apocrine glands in axillary osmidrosis have a higher expression of ApoD (ASOB2), which is consistent with higher expression of AR and pJNK. Stimulation of cultured apocrine gland epithelial cells with 5α-DHT resulted in a concentrated dependent rise in ApoD protein as well as in mRNA, indicating regulation of ApoD on both protein and mRNA levels by androgen receptor stimulation.3) The increase of ApoD could be blocked by the JNK inhibitor, demonstrating an involvement of JNK in the axillary osmidrosis. Furthermore, inhibition of JNK1 in the apocrine cells from the axillary osmidrosis subjects also reduces the endogenous expression of ApoD. Further studies are needed to confirm the role of JNK inhibition in axillary osmidrosis.4) In the study, we demonstrated a strong association between the ApoD expression and the extent of axillary osmidrosis. Our results suggest that the increased ApoD expression is one of the important characteristics of axillary osmidrosis. This expression is also much more prevalent in severe axillary osmidrosis.