Syndromes associated with nutritional deficiency and excess

Normal functioning of the human body requires a balance between nutritional intake and metabolism, and imbalances manifest as nutritional deficiencies or excess. Nutritional deficiency states are associated with social factors (war, poverty, famine, and food fads), medical illnesses with malabsorption (such as Crohn disease, cystic fibrosis, and after bariatric surgery), psychiatric illnesses (eating disorders, autism, alcoholism), and medications. Nutritional excess states result from inadvertent or intentional excessive intake. Cutaneous manifestations of nutritional imbalance can herald other systemic manifestations. This contribution discusses nutritional deficiency and excess syndromes with cutaneous manifestations of particular interest to clinical dermatologists.     

Inflammatory nail conditions. Part 1: nail changes in psoriasis

Nail changes are visible in a variety of inflammatory dermatoses. The commonest dermatological condition with nail manifestations is chronic plaque psoriasis. This two‐part article reviews the nail signs in psoriasis in Part 1, and the nail changes in cutaneous lichen planus and alopecia areata in Part 2. It provides a brief summary of the salient points in the clinical features, management and prognosis of these entities, with practical recommendations that may be beneficial to all dermatologists.     

Nutritional deficiencies and the skin

Malnutrition states are relatively uncommon in the UK but we have seen two recent cases which have heightened our awareness of both dermatological manifestations of malnutrition and of nutritional sequelae of a dermatological problem. Case 1 is a patient with anorexia nervosa presenting with features of pellagra. This condition is due to deficiency of niacin and responds rapidly to replacement therapy. Classical presentation is an erythematous rash on photoexposed sites, often related to heat or friction. There are three reported cases of pellagra occurring in patients with anorexia nervosa. Case 2 is an adult atopic with sensitizations to multiple foodstuffs. A self-imposed restriction diet caused multiple nutritional deficiencies. Restriction diets in adult atopics are not particularly common in the UK, but there is some evidence to suggest that they may cause significant nutritional deficiency. A nutrition screen may be indicated more frequently than is currently recognized.     

Acquired Protein Energy Malnutrition in Glutaric Acidemia

We report a case of acquired protein energy malnutrition with associated zinc deficiency in an 18‐month‐old boy with type 1 glutaric acidemia. Physical examination findings included generalized nonpitting edema, widespread desquamative plaques, and sparse hair with a reddish tinge. Laboratory abnormalities included low levels of zinc, albumin, alkaline phosphatase, and iron. A review of skin manifestations of nutritional deficiencies, specifically kwashiorkor, is presented, as well as the relatively new entity called acrodermatitis dysmetabolica.     

斑秃伴白癜风和盘状红斑狼疮1例

报告1例斑秃伴白癜风和盘状红斑狼疮,患者男,67岁。临床表现为头顶、两颞侧头皮片状脱发,头顶脱发区边缘出现片状白斑,面颊部两侧,耳后见境界清楚的紫红色丘疹、斑块,表面有粘着性鳞屑,鳞屑下方有角栓。结合临床和组织病理改变诊断为斑秃伴白癜风和盘状红斑狼疮。     

Teaching effects of dermatological consultations on nondermatologists in the field of internal medicine. A study of 1290 inpatients

BACKGROUND: Scarce data exist concerning dermatological consultations within departments of internal medicine. To date, no survey has been carried out in Switzerland to elucidate this issue. The aim of this study was to analyze the spectrum of skin diseases internists are confronted with and to study their diagnostic accuracy in cutaneous diseases. In addition, we wanted to evaluate the motivation for dermatologists to cooperate closely with internists. PATIENTS AND METHODS: The study included patients with dermatological problems treated at the Department of Internal Medicine at the Kantonsspital Aarau, Switzerland. All patients had been referred to the Department of Dermatology for examination between 1999 and 2001. Patient data were analyzed demographically, by referral modus, diagnoses and therapy. To evaluate the knowledge of internists and dermatologists in cutaneous medicine, 15 clinical slides of common dermatoses with a patient history were shown and asked for diagnostic suggestions to 32 internists of the Kantonsspital Aarau and to 13 dermatologists of the University Hospital Basel, Switzerland. RESULTS: 1290 patients were referred to the Department of Dermatology. 1737 dermatological diagnoses were made including 348 different dermatoses. Eczema was the single most common diagnosis (12.6%), followed by actinic and bowenoid precancerosis (6.2%), drug eruption (4.2%), verrucae (4%) and mycosis (3.8%). The top ten diagnoses accounted for 41.7% of all skin-related diagnoses. Infection-related dermatoses were most common (20.5%) followed by different types of eczema (12.6%), malignant cutaneous tumors and malignant visceral conditions (11.2%). Local therapy was prescribed in 64.2% and systemic therapy in 22.6% of the patients. 15.9% did not receive specific therapy because the consultation request was only a diagnostic one. 146 skin biopsies were performed (11.3%). Systemic diseases with cutaneous manifestations accounted for 15.7%. In general, these conditions were not commonly seen by dermatologists in daily practice. The internists recognized 51.1% of the cutaneous manifestations during examination and 49% when presented with slides. CONCLUSIONS: Internists are confronted with a different spectrum of cutaneous diseases compared with dermatologists. Due to the broad spectrum of skin diseases, it is a challenging task for internists to recognize dermatoses. Our study elucidates that patients, internists and dermatologists may profit from a close cooperation.     

Case for diagnosis

A 6 year-old patient began to experience localized hairloss in the right temporal region three years ago. During the first appointment, diagnoses of alopecia areata and congenital triangular alopecia were made. After one year, there was no change. Upon dermatological examination, non-scarring alopecia was noted in the right temporal region, revealing extremely fine and fair hair follicles. A dermoscopy revealed only thin vellus-type hairs. Congenital triangular alopecia is a condition commonly confused with alopecia areata and is thus underdiagnosed. However, well-established clinical parameters and dermoscopic criteria can be used to distinguish skin diseases that affect hair and define the diagnosis.     

Eyebrow threading: a popular hair-removal procedure and its seldom-discussed complications

Removal of eyebrow and facial hair by 'threading' has gained popularity worldwide. Threading is an ancient Eastern method of removing unwanted facial and eyebrow hair by a technique whereby one end of a cotton thread is held in the mouth of the technician and the other end looped around individual hair shafts, which are then pulled out. This is repeated in quick, successive movements. In India, this is used extensively for shaping and removing eyebrow hair. Threading now enjoys immense popularity with women worldwide, irrespective of race or colour, and is an accepted method for removing eyebrow hair and shaping the eyebrows. However, this popular cosmetic procedure has some significant dermatological side-effects and is not familiar to many dermatologists. To our knowledge, this is the first report of verrucae occurring in threaded eyebrows. Other complications include erythema, folliculitis, pseudofolliculitis, hyperpigmentation, and depigmentation, including koebnerization of vitiligo. This report should alert dermatologists to the possible complications that may arise from this popular aesthetic epilatory procedure.     

Adenosine increases anagen hair growth and thick hairs in Japanese women with female pattern hair loss: A pilot,double‐blind,randomized, placebo‐controlled trial

Adenosine upregulates the expression of vascular endothelial growth factor and fibroblast growth factor‐7 in cultured dermal papilla cells. It has been shown that, in Japanese men, adenosine improves androgenetic alopecia due to the thickening of thin hair due to hair follicle miniaturization. To investigate the efficacy and safety of adenosine treatment to improve hair loss in women, 30 Japanese women with female pattern hair loss were recruited for this double‐blind, randomized, placebo‐controlled study. Volunteers used either 0.75% adenosine lotion or a placebo lotion topically twice daily for 12 months. Efficacy was evaluated by dermatologists and by investigators and in phototrichograms. As a result, adenosine was significantly superior to the placebo according to assessments by dermatologists and investigators and by self‐assessments. Adenosine significantly increased the anagen hair growth rate and the thick hair rate. No side‐effects were encountered during the trial. Adenosine improved hair loss in Japanese women by stimulating hair growth and by thickening hair shafts. Adenosine is useful for treating female pattern hair loss in women as well as androgenetic alopecia in men.     

Confluent ecchymoses on the lower extremities of a malnourished patient.

Nutritional deficiencies result in many distinctive cutaneous manifestations. Vitamin C deficiency, or scurvy, produces follicular hyperkeratosis, perifollicular hemorrhages, gingival hypertrophy, and bleeding (1). We report here a case of malnutrition who suddenly developed extensive eccymoses on the lower extremities sharing morphological similarities with purpura fulminans. Although the patient did not have the characteristic dermatological features of scurvy, serum levels of vitamins C, K, B12, and E were decreased.     

Lichen planopilaris following hair transplantation and face-lift surgery

Cosmetic surgical procedures, including hair transplantation and face-lift surgery, are becoming increasingly popular. However, there is very little information regarding the associated development of dermatological conditions following these procedures. Lichen planopilaris (LPP) is an uncommon inflammatory hair disorder of unknown aetiology that results in permanent alopecia and replacement of hair follicles with scar-like fibrous tissue. Frontal fibrosing alopecia (FFA), a variant of LPP, involves the frontal hairline and shares similar histological findings with those of LPP. We report 10 patients who developed LPP/FFA following cosmetic scalp surgery. Seven patients developed LPP following hair transplantation, and three patients developed FFA following face-lift surgery. In all cases there was no previous history of LPP or FFA. There is currently a lack of evidence to link the procedures of hair transplantation and cosmetic face-lift surgery to LPP and FFA, respectively. This is the first case series to describe this connection and to postulate the possible pathological processes underlying the clinical observation. Explanations include Koebner phenomenon induced by surgical trauma, an autoimmune process targeting an (as yet, unknown) hair follicle antigen liberated during surgery or perhaps a postsurgery proinflammatory milieu inducing hair follicle immune privilege collapse and follicular damage in susceptible individuals.     

THE FLAG SIGN IN THE HAIR OF AN ALCOHOLIC

A patient is presented with the “flag sign” which was associated with episodic malnutrition in an alcoholic. Diminished hair diameter, flating and loss of normal cuticle were found in areas of depigmentation but were sometimes dissociated suggesting different mechanisms within the general terms of “malnutrition”.     

Evidence‐based (S3) guideline for the treatment of androgenetic alopecia in women and in men – short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence‐based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence‐based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.     

Human essential fatty acid deficiency: treatment by topical application of linoleic acid.

An essential fatty acid (EFA) deficiency developed in a 19-year-old man who was being maintained on a long-term regimen of fat-free, intravenous hyperalimentation fluids. The EFA deficiency was reversed after 21 days by daily, topical application of linoleic acid to the patient's skin. The ratio of eicosatrienoic acid (20:3, n-9) to eicosatetraenoic acid (20:4, n-6) decreased to normal levels in the skin and serum with clinical improvement of the EFA deficiency syndrome. The cutaneous manifestations (scalp dermatitis, alopecia, and depigmentation of hair) were reversed with continued, topical application of safflower oil, which contains 60% to 70% linoleic acid.     

Intravenous zinc therapy for acquired zinc deficiency secondary to gastric bypass surgery: a case report

Zinc deficiency may result from either a congenitally inherited defect of zinc absorption or is acquired secondarily from a variety of factors affecting dietary zinc intake, absorption, or loss. We report a case of acquired zinc deficiency secondary to gastric bypass surgery that resulted in vulvar cutaneous manifestations of delayed onset, with failure to clear after oral supplementation with zinc. The patient experienced improvement of symptoms only after administration of intravenous zinc supplementation. Upon review of the current literature, it is thought that the patient's original suboptimal response to oral supplementation and improvement after receiving intravenous zinc were related to the intentional surgical alteration and bypass of the absorptive capacity of the duodenum and jejunum. With the current prevalence of obesity and availability of surgical weight loss therapies, it is important to be mindful of the resulting nutritional deficiencies, their clinical manifestations, and factors affecting the efficacy of therapeutic approaches as seen in this case.     

Obsessive‐compulsive disorder in dermatology

Patients with obsessive‐compulsive (OCD) and related disorders – primarily trichotillomania, body dysmorphic disorder, and skin picking disorder – frequently present to dermatologists due to associated hair and skin symptoms. It is therefore crucial that dermatologists be familiar with these disorders. In this review article, we provide an update on clinical features, neurobiology factors, and treatment options for OCD spectrum disorders. Employing PubMed and Cochrane Library databases, a selective literature search was conducted using keywords related to dermatological disorders within the OCD spectrum. OCD and its related disorders share several phenomenological as well as pathophysiological similarities, thus warranting their classification within a separate nosological category of psychiatric disorders. Another similarity of OCD spectrum disorders is the frequent concurrence of hair and skin diseases. Besides symptomatic dermatological treatment, the combination of psychotherapy (behavioral therapy) and psychopharmacotherapy (SSRIs) may be helpful. Although recent insights into OCD have contributed to a better understanding and treatment thereof, more research is required, especially with respect to OCD spectrum disorders, for which large controlled treatment studies are still lacking.     

Skin manifestations in solid organ transplant recipients

The clinical spectrum of the most significant dermatological complications of solid organ transplantations is presented in an attempt to enhance the awareness among dermatologists and other physicians of the importance of careful dermatological monitoring of organ transplant recipients for early diagnosis and prompt treatment of these manifestations.     

When your patient's parent asks: “My child's alopecia areata is not getting better. Should he or she get tested for celiac disease?”

The relationship between alopecia areata and celiac disease has been suspected for more than 20 years. For a particular individual with alopecia areata, the risk of coexisting celiac disease and the potential benefit of a gluten‐free diet on hair loss or regrowth is known. Despite this limited information, patients often aske dermatologists whether they should undergo celiac disease testing or begin a gluten‐free diet. We reviewed all available studies of the relationship between alopecia areata and celiac disease to provide guidance to practicing clinicians.     

Dermatological manifestations of tuberous sclerosis complex (TSC)

Tuberous sclerosis complex (TSC) is a genetic multisystem disorder with prominent skin involvement that frequently occurs in early childhood. Dermatologic manifestations include facial angiofibromas, hypomelanotic macules, fibrous cephalic plaques, shagreen patches, and ungual fibromas. The International TSC Consensus Conference in 2012 provided guidelines for standardized baseline evaluation and follow‐up. Detailed clinical dermatological evaluation at the time of diagnosis and annual skin examination is recommended for both pediatric and adult populations. The onset of dermatological manifestations is clearly age‐related. However, dermatologists also have to assess for clinical manifestations beyond their own specialty. With advances in genetics and the advent of mTORC1 inhibitors, new specific therapeutic options have become available for TSC patients with skin manifestations. Early intervention is commonly recommended for symptomatic, rapidly evolving, disfiguring, or debilitating lesions. The consensus guidelines recommend “treatment as appropriate for the lesion and clinical context” and suggest the use of surgical excision, laser therapy, or topical mTORC1 inhibitors. Topical mTORC1 inhibitors present a useful option for TSC‐associated skin lesions, particularly in medically complex patients. They may prevent or reduce the risks of subsequent surgeries and permanent scarring.     

Presenting skin disorders in black Afro-Caribbean patients: a multicentre study conducted in the Paris region

BACKGROUND: There have been few studies in France concerning the specific features of dermatological practice regarding dark skin (Fitzpatrick's phototype V and VI) or the special requirements of black African and Afro-Caribbean patients. AIM: To determine the principal reasons for dermatological consultation among black patients of African or Afro-Caribbean descent in the Paris region. METHODS: This was a prospective clinical study conducted between 15 February and 15 May 2004. The diagnoses of cutaneous conditions leading to dermatological consultation for all black patients of phototype V to VI were recorded by 10 dermatologists practicing in 14 centres within the Paris region. LIMITS: The method used did not allow any conclusions to be drawn regarding the incidence of the presenting conditions among the global population nor did it allow comparison between populations of different phototypes. The absence of any preset list of diagnoses or of precise inclusion criteria regarding evaluation of skin colour left individual investigators with a broad margin of interpretation. RESULTS: In 836 adults and 228 children (half of whom were from Africa and half from the West Indies), diagnoses were as follows: acne in 29.2% of adults and 13.2% in children, and eczema in 6.8% of adults and 27.2% of children. Among dermatoses more specific to black subjects, scalp conditions were frequently seen in both adults (alopecia 7% of diagnoses) and children (tinea capitis 9.6% and alopecia 3.6% of diagnoses). In at least 25% of cases, consultation was associated with dyschromia. Clinical signs suggesting the use of skin lightening products were seen in 95 patients. CONCLUSION: In France, as in other industrialized countries, black patients consult dermatologists essentially for common benign dermatoses also seen amongst white people. Nevertheless, it is important to emphasise the presence of skin problems specific to black patients such as dyschromia and pigmentary disorders, hair and scalp dermatoses, and side effects associated with the use of skin lightening products.