Post on 12-Feb-2016
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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