Cutaneous signs of 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, and metabolic, renal, hepatic, and inherited disorders. Nutrients include protein, carbohydrate, fat, vitamins, minerals, and trace elements.

Heath ML, Sidbury R: Cutaneous manifestations of nutritional deficiency, Curr Opin Pediatr 18:417–422, 2006.

Marasmus (from the Greek meaning wasting), or childhood caloric malnutrition, is a combined or proportional energy and protein deficiency with resultant catabolism and utilization of muscle and fat. There are no specific or significant skin findings. Infants often demonstrate a “monkey facies” due to loss of buccal fat that normally gives the face a rounded appearance.

Oumeish OY, Oumiesh I: Nutritional skin problems in children, Clin Dermatol 21:260–263, 2003.

Kwashiorkor (from the Ga language of Ghana, meaning “sickness of the weanling”), or childhood protein malnutrition, is a result of protein deficiency with concurrent normal to excessive carbohydrate intake. It is a common affliction worldwide, and is seen in developed countries in association with poverty, neurologic disease, and malabsorption. There is muscle wasting with preservation of normal fat stores. The low ratio of protein to energy is felt to disrupt the body’s usual hypometabolic response to caloric deficiency and is biochemically manifest as markedly increased lipid peroxidation. Clinically, edema, hypoalbuminemia, growth retardation, fatty liver, psychomotor changes, and prominent skin findings are seen.

Lenhartz H, Ndasi R, Anninos A, et al: The clinical manifestation of the kwashiorkor syndrome is related to increased lipid peroxidation, J Pediatr 132:879–881, 1998.

In black children, initial circumoral pallor progresses to diffuse depigmentation. In white children, there is diffuse blanching erythema that rapidly progresses to dusky nonblanching purple macules and papules. Classic findings include mosaic skin (dry, fine areas of desquamation with cracking along skin lines) and enamel paint dermatosis (Fig. 40-1), which evolves into large areas of erosion and desquamation. Hair in affected patients is sparse, thin, fragile, and depigmented. This hair depigmentation may produce the flag sign, which is alternating pigmented and depigmented bands seen along the hair shafts corresponding to periods of normal and inadequate nutrition.

Buno IJ, Morelli JG, Weston WL: The enamel paint sign in the dermatologic diagnosis of early-onset Kwashiorkor, Arch Dermatol 134:107–108, 1998.

Essential fatty acid deficiency occurs with deficiency of linoleic acid, a precursor of arachidonic acid. It is seen primarily with malabsorption syndromes and with prolonged total parenteral nutrition. Skin findings consist of a periorificial or generalized dermatitis caused by increased transepidermal water loss due to loss of the barrier function of the skin. Periorificial dermatitis cannot be clinically differentiated from lesions seen in acrodermatitis enteropathica (see question 18). Dietary or intravenous linoleic acid supplementation is curative, although adults often respond to only topical application.

Smit EN, Muskiet FA, Boersma ER: The possible role of essential fatty acids in the pathophysiology of malnutrition: a review, Prostaglandins Leukot Essent Fatty Acids 71:241–250, 2004.

Yes. Obesity researchers have documented an increased incidence of plantar hyperkeratosis (thickened soles), acanthosis nigricans, striae, and skin tags in patients overweight by more than 100%. Excess fat deposition predisposes to intertrigo, a dermatitis occurring between skinfolds, sometimes associated with secondary bacterial or candidal infection.

Yosipovitch G, DeVore A, Dawn A: Obesity and the skin: skin physiology and skin manifestations of obesity, J Am Acad Dermatol 56:901–916, 2007.