Being a doctor can stink: How to discuss B.O. with patients

You know it when you smell it—some patients simply have bad body odor. Unfortunately, it’s not something you can discuss as easily as, say, a sore throat: “I notice that you stink. But there’s a prescription for that. It’s called soap.” Truth is, if you want to help (and to keep) your patient, you need to discuss it very tactfully. Here’s how.

Where B.O. comes from

First, let’s review what body odor actually is. One thing to know: your sweat doesn’t stink. That’s right, sweat itself (water, salts, and lactic acid released from eccrine glands, plus oils, steroids, and proteins from apocrine glands) has no smell. But when the bacteria on your skin breaks down the proteins in your sweat, that’s where the smell comes from.

Poor hygiene, eating spicy/pungent foods (garlic, curry, etc), and/or having certain conditions—such as obesity, diabetes, inflammation or infection between skin folds, or excessive sweating (hyperhidrosis)—are all factors associated with body odor.

People with unusually strong and offensive body odor have bromhidrosis, which occurs when sweat glands produce an excessive amount of secretion. Researchers have found that people with bromhidrosis have larger and more numerous apocrine glands.

How to talk about B.O.

Don’t turn your nose up when a patient has bad B.O.—you must address the situation. Bad body odor can be a symptom of a more serious problem. Even if it isn’t, proper hygiene is an aspect of a patient’s overall health that you shouldn’t ignore.

As a clinician, you’re used to having difficult and sometimes awkward conversations with your patients. That’s a good place to start. Acknowledge to the patient that you want to discuss a situation that you admit is difficult to talk about. Don’t beat around the bush and, for heaven’s sake, don’t make a joke out of it. Be honest and direct without being too blunt or insensitive. Say something like, “I’d like to talk to you about something that’s awkward, and I hope I don’t offend you. But I want you to be aware that you have a noticeable odor.”

Take note that these words don’t place blame or shame on the patient by calling it a “problem” or describing it as an “offensive” or even “bad” odor. If the patient acknowledges awareness of the odor, then begin an educational discussion about how to deal with it (see below).

But if the patient disagrees or isn’t aware of the odor, say something like, “This can be the kind of thing that people often don’t realize about themselves, so I wanted to bring it to your attention and talk about what we can do about it. It could be as simple as washing your clothes more often or showering more frequently, or it may be a medical problem.”

If the patient still disagrees, there’s not much more you can do at this point other than make a note to bring it up again (if necessary) at the patient’s next visit. But, more likely than not, the patient will either admit awareness of the odor or at least be willing to listen and discuss it further.

Education and management of B.O.

Conservative treatment begins with educating the patient about improved hygiene, including:

• Daily and thorough bathing with warm/hot water (including armpits, genital areas, feet, and between skin folds)
• Wearing clean, breathable clothes
• Daily use of antiperspirant

High-strength antiperspirants (containing a higher percentage of active ingredient, typically aluminum chloride hexahydrate) are available over-the-counter or by prescription. In addition, shaving armpits may help by preventing sweat and bacteria from accumulating on axillary hair.

If conservative treatment fails to eliminate the odor, consider more advanced treatments. Botox (onabotulinumtoxinA) injections, for example, can be used to deaden the sweat glands, preventing them from releasing secretions. The treatment typically lasts 6-8 months. Possible side effects include injection-site pain and flu-like symptoms.

Permanent procedures to remove the sweat glands include radiofrequency or laser ablation, surgical excision, subcutaneous liposuction, and surgical sympathectomy. Compensatory sweating is a potential, undesirable side effect of the latter procedure.

Tactfully addressing bad body odor is truly good medicine—it can significantly improve a patient’s hygiene and quality of life.