Cutaneous Signs of Nutritional Disturbances

1

When do skin abnormalities occur in association with nutritional disturbances?

Skin manifestations occur when structural or enzymatic processes are affected by a deficiency or excess of a particular nutrient. This can be seen with dietary insufficiency or excess, malabsorption, drug interference, catabolic states, as well as metabolic, renal, hepatic, and inherited disorders. Nutrients are classified as macronutrients (protein, carbohydrate, fat), micronutrients (vitamins, minerals), and trace elements.

2

Do nutritional disturbances involve the skin exclusively?

Absolutely not. Nutritional disorders are generalized conditions that cause adverse effects in many organ systems. Clinical history, review of systems, and physical examination are of utmost importance when determining the underlying etiology of skin findings suggestive of a nutritional disorder. As isolated nutritional disturbances are uncommon, a thorough evaluation should be undertaken when an imbalance is suspected.

3

Which skin changes are seen with protein and calorie deprivation in adults?

In general, adults with starvation demonstrate rough, pallid, lax skin with frequent dyschromia favoring the malar and periorificial areas. Hair is thinned, and nail growth is slow with frequent fissuring. There is decreased subcutaneous fat and, with time, muscle wasting may develop.

4

What is marasmus?

Marasmus (from the Greek meaning wasting ) is a disorder of total calorie (energy) deficiency with resultant catabolism and utilization of muscle and fat. Infants in developing countries are at highest risk for marasmus, and affected patients often demonstrate an emaciated “monkey facies” due to loss of buccal fat that normally gives the face a rounded appearance. Other associated skin findings are nonspecific and may include dry, loose skin and thin, fragile hair.

5

What is kwashiorkor?

Kwashiorkor (from the Ga language of Ghana, meaning “sickness of the weanling”) is a result of protein deficiency with concurrent normal to excessive carbohydrate intake. Risk factors include poverty, neurologic disease, and malabsorption. There is pronounced muscle wasting with preservation of normal fat stores, failure to thrive, and marked edema that can progress to anasarca. A genetic predisposition to enterocyte loss of heparan sulfate proteoglycan (HSPG) appears to explain the clinical findings of edema, hypoalbuminemia, growth retardation, fatty liver, psychomotor disturbances, and skin changes seen in affected patients.

6

Describe the skin findings in kwashiorkor

Classic skin findings in kwashiorkor include mosaic skin (dry, fine areas of desquamation with cracking along skin lines) and “enamel paint” dermatosis ( Fig. 39.1 ), which evolves into large areas of erosion and desquamation. In black children with kwashiorkor, initial circumoral pallor progresses to diffuse depigmentation, whereas affected white children often exhibit diffuse blanching erythema that rapidly progresses to dusky nonblanching purple macules and papules. Hair in affected patients is sparse, fragile, and depigmented. On trichogram analysis, the flag sign may be observed in the form of alternating pigmented and depigmented bands seen along the hair shafts corresponding to periods of adequate and inadequate protein consumption, respectfully.

7

How can I remember the differences in skin findings associated with kwashiorkor and marasmus?

Kwashiorkor, or protein malnutrition, may be memorized by thinking of “KP,” the often utilized military abbreviation for “kitchen patrol.” Kwashiorkor is associated with peeling skin, akin to the often affected hands of dishwashers.

8