SKIN MANIFESTATIONS of NUTRITIONAL DISORDERS

Food ingestion ~ healthFood ingestion ~ health skin conditionskin condition Nutritional deficiencies Nutritional deficiencies alterations in alterations in

photoprotection, immune function and photoprotection, immune function and homeostasishomeostasis

Mucocutaneous changes Mucocutaneous changes most most frequent manifestations of frequent manifestations of malnutritionmalnutrition

Protein-energy malnutritionProtein-energy malnutrition

Comprises quantitative and qualitative Comprises quantitative and qualitative defects in the ingestion and / or defects in the ingestion and / or utilization of nutrientsutilization of nutrients

Inadequate body weightInadequate body weight Developmental and physiological Developmental and physiological

alterationsalterations

ClassificationClassification

MarasmusMarasmus - failure in weight gain, leading to - failure in weight gain, leading to

emaciationemaciation - skin - skin dry, thin, pale lax & wrinkled dry, thin, pale lax & wrinkled - subcutaneous fat disappears- subcutaneous fat disappears - muscles - muscles considerable loss in volume considerable loss in volume - basal metabolism is diminished- basal metabolism is diminished - body temperature is low- body temperature is low

KwashiorkorKwashiorkor - wet malnutrition- wet malnutrition - oedema, failure to thrive- oedema, failure to thrive - loss of muscle mass- loss of muscle mass

Cutaneous manifestationsCutaneous manifestations

MarasmusMarasmus - Skin - Skin thin, lax or wrinkled, scaly & thin, lax or wrinkled, scaly & hyperpigmentedhyperpigmented - excess lanugo-like hair- excess lanugo-like hair - loss of buccal fat pads - loss of buccal fat pads monkey faces, monkey faces, aged appearanceaged appearance - hair - hair brittle brittle - nail - nail thin & fissured thin & fissured - angular cheilitis, pale & atrophic tongue - angular cheilitis, pale & atrophic tongue

Nail Changes During PCM - Nail Changes During PCM - Note Brittle Nail Being Note Brittle Nail Being Replaced by Normal Nail as Replaced by Normal Nail as Client FedClient Fed

KwashiorkorKwashiorkor - hyperpigmentation & occasional fissuring- hyperpigmentation & occasional fissuring in areas subject to pressurein areas subject to pressure - erythema, desquamation, thinning,- erythema, desquamation, thinning, ptechiae, ecchymosis and purpuraptechiae, ecchymosis and purpura - shiny varnished-like skin (64%), dark - shiny varnished-like skin (64%), dark erythemateous pigmented macules (48%),erythemateous pigmented macules (48%), xerotic ‘crazy-paving’ skin (28%), residualxerotic ‘crazy-paving’ skin (28%), residual hypochromia (21%), large-scale hypochromia (21%), large-scale

desquamationdesquamation (18%)(18%)

Superimposed bacterial & mycotic Superimposed bacterial & mycotic (candida)(candida)

Hair Hair sparse, thin & depigmented sparse, thin & depigmented Periodic episodes Periodic episodes ‘flag sign’ ‘flag sign’

ManagementManagement

Multidisciplinary approachMultidisciplinary approach Skin lesions regress as soon as Skin lesions regress as soon as

receives adequate dietary intake receives adequate dietary intake Acute phase Acute phase lubricating ointments lubricating ointments Bacterial infections Bacterial infections AB AB Candida infection Candida infection topical agents topical agents

Fatty acid deficiencyFatty acid deficiency

Low-fat diets, severe malabsorption, Low-fat diets, severe malabsorption, long term parenteral nutrition, in long term parenteral nutrition, in association with PEMassociation with PEM

Skin Skin dry, scaly, underlying dry, scaly, underlying erythema, intertriginous erosions, erythema, intertriginous erosions, alopeciaalopecia

Treatment : EFA replacementTreatment : EFA replacement

Vitamin A deficiencyVitamin A deficiency

Follicular papules with a central Follicular papules with a central keratotic plug, primary on the extensor keratotic plug, primary on the extensor extremitiesextremities

Skin Skin dry, scaly dry, scaly Hair Hair sparse & fragile sparse & fragile

Follicular Hyperkeratosis of Follicular Hyperkeratosis of Vitamin A DeficiencyVitamin A Deficiency

Hypervitaminosis AHypervitaminosis A

Most cases due to oral therapyMost cases due to oral therapy Erythema, skin fragility, desquamation, Erythema, skin fragility, desquamation,

mucosal dryness, diffuse alopeciamucosal dryness, diffuse alopecia Carotenoderma Carotenoderma - orange-yellow skin pigmentation due to- orange-yellow skin pigmentation due to high intake of ß-carotenehigh intake of ß-carotene - disappear when dietary habits are - disappear when dietary habits are

regulatedregulated

Vit B2 (riboflavin) deficiency Cheilitis, depapillated glossitis, Cheilitis, depapillated glossitis,

pruritus, seborrhoeic-like pruritus, seborrhoeic-like desquamation, scrotal dermatitisdesquamation, scrotal dermatitis

Keratitis, conjunctivitis, photophobia, Keratitis, conjunctivitis, photophobia, tearingtearing

Mild cases Mild cases 3 – 10 mg /d/o 3 – 10 mg /d/o Severe cases Severe cases parenteral parenteral

Vitamin B3 deficiencyVitamin B3 deficiency Pellagra Pellagra classic clinical menifestation classic clinical menifestation

dermatitis, diarrhoea, dementiadermatitis, diarrhoea, dementia Associated with : Associated with : - nutritional deprivation- nutritional deprivation - rich maize diet- rich maize diet - alcoholism- alcoholism - impaired absorption of tryptophan- impaired absorption of tryptophan - GI disease, psychiatric disturbances- GI disease, psychiatric disturbances

Cutaneous manifestation : symmetrical Cutaneous manifestation : symmetrical erythema on light exposed area (hands, erythema on light exposed area (hands, neck, face) neck, face) scarlet, hyperpigmented, scarlet, hyperpigmented, desquamating, crusteddesquamating, crusted

Mucosal Mucosal cheilitis, red, atrophic cheilitis, red, atrophic glossitis, perianal & vaginal glossitis, perianal & vaginal inflmmation, paininflmmation, pain

Prolonged patients Prolonged patients neurological neurological manifestationsmanifestations

Treatment : Treatment : - 300 mg / o niacin- 300 mg / o niacin - 100 mg / iv- 100 mg / iv - adequate well-balanced diet- adequate well-balanced diet

Vitamin B6 (pyridoxine)Vitamin B6 (pyridoxine) Skin lesions : Skin lesions : - cheilosis- cheilosis - glossitis- glossitis - conjunctivitis- conjunctivitis - periorificial seborrhoeic-like - periorificial seborrhoeic-like

dermatitisdermatitis Treatment : Treatment : - 20 – 100 mg /d/o- 20 – 100 mg /d/o - 100 mg / im in cases of convulsions- 100 mg / im in cases of convulsions

Vitamin B12 Vitamin B12 (cyanocobalamin)(cyanocobalamin) Mucocutaneous alterations are rare Mucocutaneous alterations are rare hyperpigmentation of flexural areas, hyperpigmentation of flexural areas,

palms, soles, nails, oral cavitypalms, soles, nails, oral cavity Th/ : 1 mg vit B12 once/month/imTh/ : 1 mg vit B12 once/month/im

Biotin deficiency may be genetic or Biotin deficiency may be genetic or acquiredacquired

Ingestion of raw egg white (avidine) Ingestion of raw egg white (avidine) and malabsorption and malabsorption main causes main causes

Biotin (vitamin H)Biotin (vitamin H)

Periorificial erythematous, scaling Periorificial erythematous, scaling dermatitis, pallor, atrophic papilla of dermatitis, pallor, atrophic papilla of the tongue, diffuse alopecia with the tongue, diffuse alopecia with hypopigmented hairhypopigmented hair

Acquired biotin deficiency : eczema. Acquired biotin deficiency : eczema. Alopecia, conjunctivitis, parasthesiae, Alopecia, conjunctivitis, parasthesiae, muscle painmuscle pain

Th/: 10 – 30 mg biotin /o/dTh/: 10 – 30 mg biotin /o/d

Vitamin C (Ascorbic acid)

Clinical manifestation : scurvy Clinical manifestation : scurvy irritability, pseudoparalysis of the legs irritability, pseudoparalysis of the legs (frog position), osseous alterations, (frog position), osseous alterations, haemorrhage, anemia haemorrhage, anemia

Bluish-purple and painful swellings of Bluish-purple and painful swellings of the gum, follicular hyperkeratosis, the gum, follicular hyperkeratosis, haemorrhages in the skin range from haemorrhages in the skin range from ptechia to ecchymosesptechia to ecchymoses

Th/ : 150 mg/d of ascorbic acidTh/ : 150 mg/d of ascorbic acid

Patient With Multiple Deficiencies Patient With Multiple Deficiencies exhibits cheilosis, glossitis, and exhibits cheilosis, glossitis, and scorbutic gumsscorbutic gums

SeleniumSelenium Hypopigmentation of the skin, hair & Hypopigmentation of the skin, hair &

nails (white nails).nails (white nails). Selenium supplementation 2 mg/kg/dSelenium supplementation 2 mg/kg/d Se sulphide shampoo Se sulphide shampoo used in used in

pityriasis capitis, pityriasis vesicolor, pityriasis capitis, pityriasis vesicolor, seborrhoeic dermatitisseborrhoeic dermatitis

Excessive absorption through damaged Excessive absorption through damaged skin may cause tremor and loss of skin may cause tremor and loss of appetiteappetite

ZincZinc Factors in the pathogenesis of deficiency : Factors in the pathogenesis of deficiency :

- low zinc content in the diet- low zinc content in the diet - consumption of substances that - consumption of substances that

interfere interfere with zinc bioavailability (phytate)with zinc bioavailability (phytate) - homeostatic incapacity of the individual- homeostatic incapacity of the individual to retain zincto retain zinc - increased need for zinc (pregnancy)- increased need for zinc (pregnancy)

Acrodermatitis enteropathica Acrodermatitis enteropathica classic classic condition due to Zn deficiency condition due to Zn deficiency triad triad of dermatitis, diarrhoea and alopeciaof dermatitis, diarrhoea and alopecia

Cutaneous lesion : periorificial Cutaneous lesion : periorificial erythematous, scaling plaques, erosionerythematous, scaling plaques, erosion

Frequently complicated by candidiasisFrequently complicated by candidiasis

Anorexia nervosa / bulimiaAnorexia nervosa / bulimia

Dry skin, hyperpigmentation, skin Dry skin, hyperpigmentation, skin roughness, generalized lanugo-like roughness, generalized lanugo-like hair, diffuse alopecia, brittle hair & hair, diffuse alopecia, brittle hair & nailsnails

Ecchymoses due to vitamin K Ecchymoses due to vitamin K deficiencydeficiency

Advanced cases Advanced cases scurvy & pellagra scurvy & pellagra

ObesityObesity

Cutaneous alterations are related to Cutaneous alterations are related to friction, accumulated moisture, friction, accumulated moisture, overheating, oversweating in fat overheating, oversweating in fat skinfoldsskinfolds

Friction between skin surfaces leads to Friction between skin surfaces leads to hyperpigmentationhyperpigmentation