Understanding Nutritional Dermatoses

What Is Malnutrition?

Malnutrition refers to deficiencies, excesses, or imbalances in a person's energy intake or nutrients. It is a significant public health issue worldwide. The World Health Organization considers malnutrition one of the most critical risk factors for illness and premature death. Malnutrition is often associated with poverty in developing countries. Therefore, it is underdiagnosed or misdiagnosed in developed countries. Delayed diagnosis and treatment can lead to disabilities and sometimes may cause death. Skin manifestations are often the early signs of malnutrition.

What Causes Malnutrition?

Protein-energy malnutrition (PEM) is a form of nutrition caused by shortages or inappropriate use of food supplies. It is most common in preschool children in developing countries because of their less protein intake. Malnutrition in developed countries is primarily associated with chronic illness, gastrointestinal (GI) disease, or restrictive dietary habits. Identifying the skin manifestations associated with nutritional abnormalities is essential, as early detection can correct these deficiencies.

1. Protein-Energy Malnutrition:

Kwashiorkor and marasmus are the primary forms of acquired protein-energy malnutrition (PEM). Kwashiorkor results from chronic protein deficiency despite adequate caloric intake. In contrast, marasmus is caused by insufficient total caloric intake.

Symptoms:

Marasmus:

• Weight loss, dehydration, and stomach shrinkage give the children sunken cheeks and an aged appearance.

• The skin becomes dry and thin with wrinkling. Mental status changes can be observed in severe cases.

Kwashiorkor:

• Children with kwashiorkor are often irritable. These children often have a protuberant belly, a common feature of kwashiorkor attributed to an enlarged, fatty liver and possible ascites (abnormal fluid buildup in the abdomen).

• Pigment alterations in the form of hypo or hyperpigmentation are the most common skin finding in people with kwashiorkor.

• Their hair is often dry, sparse, and lighter in color.

• Kwashiorkor usually has a concurrent zinc deficiency. Therefore, it may also manifest with growth retardation and immune dysfunction.

2. Essential Fatty Acids Deficiency (EFAD):

Essential fatty acids (EFAs) are vital macronutrients. Essential fatty acids from the sources like dairy products, meat, and vegetable oils are necessary structural components of cell membranes and play an integral role in the skin's barrier mechanism.

Symptoms:

People with an essential fatty acid deficiency may have the following symptoms:

• Severe dry and scaly skin, prominent skin inflammation, and desquamation (damage or loss of the upper layer of the skin).

• Increased capillary fragility, increased susceptibility to infection, poor wound healing, fatty liver, and growth retardation.

• Hair loss of the scalp and eyebrows and loss of skin pigmentation.

3. Vitamin A Deficiency:

Vitamin A (or retinol) is a fat-soluble vitamin that supports skin, eye, reproductive health, and immune function. Vitamin A is found as retinyl esters in animal products such as cow's milk, liver, egg, fish oils, green leafy vegetables, and bright yellow orange-colored fruits and vegetables.

Symptoms:

People with vitamin A deficiency may have the following symptoms:

• Night Blindness: It causes trouble seeing in low light and eventually leads to complete blindness at night.

• Xerophthalmia: The eyes may become very dry and crusted, damaging the cornea and retina.

• Infection: People living with vitamin A deficiency may experience more frequent health problems due to the inability to fight infections easily.

• Bitot Spots: This condition is a formation of a foamy silver-gray patch consisting of keratin in the eyes, causing hazy vision.

• Skin Irritation: People experiencing vitamin A deficiency can have problems with dry, itchy, and scaly skin (xerosis).

• Keratomalacia: This is an eye disorder causing drying and clouding of the cornea.

• ‌Keratinisation: It is a process by which cells become filled with keratin protein, die, and form rigid, resistant structures in the urinary, gastrointestinal and respiratory tracts.

• Stunted Growth: Vitamin A deficiency can cause delayed development, slow bone growth, or stunted growth.

• Fertility: A deficiency in vitamin A may cause challenges when trying to conceive a child and, in some cases, may lead to infertility.

4. Vitamin B3 Deficiency:

Pellagra is a systemic disease caused due to lack of niacin (vitamin B3) or tryptophan (an amino acid). It may also develop due to gastrointestinal disorders, weight loss, anorexia, excessive alcohol use, and certain medicines, such as Isoniazid, 5-Fluorouracil, 6-Mercaptopurine, Pyrazinamide, Hydantoin, Ethionamide, Phenobarbital, Pzathioprine, and Chloramphenicol.

Symptoms:

Pellagra may lead to:

• Delusions or mental confusion.

• Diarrhea, weakness.

• Appetite loss.

• Pain in the abdomen.

• Inflammation in the mucous membrane and scaly skin sores, especially in sun-exposed areas of the skin.

5. Vitamin C Deficiency (Scurvy):

Vitamin C is a crucial antioxidant that plays essential roles, including immune system support, iron absorption, and collagen production. Citrus fruits such as oranges, grapes, and strawberries, and vegetables like tomatoes, broccoli, potatoes, and bell peppers are good sources of vitamin C. Vitamin C (ascorbic acid) deficiency causes a disease called scurvy.

Symptoms:

People experiencing scurvy may report :

• Fatigue.

• Malaise.

• Loss of appetite.

• Follicular hyperkeratosis (excessive buildup of keratin in hair follicles), skin ecchymosis (bleeding under the skin due to trauma, and poor wound healing.

• Coiled "corkscrew" hairs and hairs bent into 'swan-neck' deformity.

• Intraoral manifestations have been reported, such as gum bleeding, necrosis, and poor dentition.

6. Biotin Deficiency:

Biotin (vitamin H or vitamin B7) is a water-soluble vitamin. Biotin helps break down fat and carbohydrates from the foods that produce energy. It is also recommended for strengthening hair and nails. Foods rich in biotin are eggs, nuts, whole grains and cereals, cauliflower, banana, and other legumes.

Symptoms:

Biotin deficiency presents with:

• Red rashes on the skin, dry skin, and eyes.

• Brittle hair and hair loss.

• Fatigue.

• Difficulty sleeping.

• Appetite loss.

• Depression.

• Nausea.

• Frequently upset stomach.

• Cracking in the mouth corners.

• Seizures.

• Difficulty walking.

7. Zinc Deficiency:

Zinc is an essential trace element found naturally in food items such as red meat, poultry, and fish. It aids human health, DNA synthesis, immune function, and growth. Zinc is found throughout the body. It is required for immune function, wound healing, blood clotting, and thyroid function. It also plays a crucial role in maintaining vision and may have effects against viruses. The body cannot store or produce zinc, so it is essential to have zinc in the diet.

Symptoms:

Symptoms of zinc deficiency include:

• Diarrhea.

• Delayed wound healing.

• Weakened immune system.

• More prone to infections.

• Skin rashes, particularly around the mouth, and skin ulcers.

• Weight loss.

• Hair loss.

• Abnormal taste or smell.

• Sexual dysfunction.

• Difficulty concentrating.

• Children with zinc deficiency are irritable, have problems eating and sleeping, and have impaired growth.

Conclusion

A growing body of literature suggests that malnutrition deficiencies are high among infants from developed and developing countries. Thus, it is crucial to recognize early symptoms of nutritional deficiencies, following which appropriate treatment will improve prognosis. Health professionals should create public awareness by educating the general population about dietary deficiencies. A dietary consult is recommended, as patients should know the importance of a balanced diet to avoid nutritional deficiency.