Dermatologic findings in anorexia and bulimia nervosa of childhood and adolescence

Skin signs in eating disorders: a literature review

PURPOSE

To summarize and describe the available knowledge on dermatological manifestation of eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders IV-TR and 5th edition.

METHODS

We searched in PubMed, Scopus and Web of Science databases from January 1, 1980 through May 1, 2020 for papers in English language on the skin manifestation of eating disorders. Results were screened using the PRISMA tool.

RESULTS

The study yielded 207 results. According with PRISMA guidelines, 26 papers were included in the review. More than 73% of screened papers (19/26) were case reports. Cross-sectional studies represented the 19.2% of screened papers (5/26). Each eligible study has been screened and analyzed.

CONCLUSION

Huge heterogeneity of skin signs of eating disorders were identified. The number of controlled studies available is very limited, and most papers of interest are case reports or narrative review articles. Larger, more methodologically rigorous studies to evaluate the presence of dermatological issue in eating disorder patients are needed.

LEVEL OF EVIDENCE

Level IV. Evidence obtained from multiple time series analysis such as case studies.

The Central Role of Hypothermia and Hyperactivity in Anorexia Nervosa: A Hypothesis

Typically, the development of anorexia nervosa (AN) is attributed to psycho-social causes. Several researchers have recently challenged this view and suggested that hypothermia and hyperactivity (HyAc) are central to AN. The following hypothesis will attempt to clarify their role in AN. Anorexia nervosa patients (ANs) have significantly lower core temperatures (T_core) compared to healthy controls (HCs). This reduced temperature represents a reset T_core that needs to be maintained. However, ANs cannot maintain this T_core due primarily to a reduced basal metabolic rate (BMR); BMR usually supplies heat to sustain T_core. Therefore, to generate the requisite heat, ANs revert to the behavioral-thermoregulatory strategy of HyAc. The majority of ANs (~89%) are reportedly HyAc. Surprisingly, engagement in HyAc is not motivated by a conscious awareness of low T_core, but rather by the innocuous sensation of "cold- hands" frequently reported by ANs. That is, local hand-thermoreceptors signal the brain to initiate HyAc, which boosts perfusion of the hands and alters the sensation of "cold-discomfort" to one of "comfort." This "rewarding" consequence encourages repetition/habit formation. Simultaneously, hyperactivity increases the availability of heat to assist with the preservation of T_core. Additionally, HyAc induces the synthesis of specific brain neuromodulators that suppress food intake and further promote HyAc; this outcome helps preserve low weight and perpetuates this vicious cycle. Based on this hypothesis and supported by rodent research, external heat availability should reduce the compulsion to be HyAc to thermoregulate. A reduction in HyAc should decrease the production of brain neuromodulators that suppress appetite. If verified, hopefully, this hypothesis will assist with the development of novel treatments to aid in the resolution of this intractable condition.

Hair endocannabinoid concentrations in individuals with acute and weight-recovered anorexia nervosa

BACKGROUND

The endocannabinoid system has been suggested to modulate energy metabolism and stress response and could be an important factor in the pathophysiology of anorexia nervosa (AN). In the context of AN, excessive physical activity may influence endocannabinoid concentrations. The objective of this study was to investigate hair endocannabinoid concentrations at different stages of the disorder. Measurement in hair allows for a cumulative assessment of endocannabinoid concentrations independent of circadian rhythms.

METHODS

In a combined cross-sectional and longitudinal design, we measured hair concentrations of the endocannabinoids anandamide and 2-arachidonoylglycerol and the endocannabinoid-related compounds palmitoylethanolamide, oleoylethanolamide, and stearoylethanolamide in female underweight patients with acute AN (n = 67, reassessment of n = 47 after short-term weight restoration with a body mass index increase of at least 14%), individuals long-term recovered from AN (n = 27), and healthy control participants (n = 84).

RESULTS

Hair concentrations of anandamide and all endocannabinoid-related compounds were elevated in acute AN and decreased over the course of short-term weight restoration. Anandamide concentrations remained elevated in long-term recovered AN patients. In long-term recovered patients, physical activity correlated positively with the concentrations of all endocannabinoid-related compounds.

CONCLUSION

The current study provides evidence for a significant alteration of the endocannabinoid system in acute AN, which may partly persist into long-term recovery. The endocannabinoid system may be a possible target for pharmaceutical interventions in AN, which should be explored in further preclinical and subsequently clinical randomized controlled trials.

Scurvy: An Unexpected Nutritional Complication in an Adolescent Female With Anorexia Nervosa

Vitamin C deficiency results in the clinical presentation of scurvy, a disease that is rare among the adolescent population. Individuals with unusual dietary habits, mental illness, or physical disability are more prone to develop scurvy. We present a case report of a previously healthy 16-year-old female presented to the hospital with a 12-month history of anorexia nervosa, restrictive subtype. She was admitted to the intensive care unit and transferred to a tertiary care pediatric eating disorder program for the treatment of extreme weight loss, cardiovascular instability, and refeeding syndrome. On examination, she had multiple tiny hyperpigmented perifollicular petechial papules on the lower abdomen, dorsum thighs, and extensor surfaces of the arms with corkscrew hairs on the abdomen. Dermatologic examination and laboratory investigations were consistent with a diagnosis of scurvy. The patient's vitamin C serum level was 21 μmol/L (.23 mg/dL; reference range 25-114 μmol/L [.28-1.28 mg/dL]). She was treated with ascorbic acid orally. Objective cutaneous findings improved within 4 weeks of supplementation, and after 6 weeks, repeat levels of vitamin C levels were 102 μmol/L (1.15 mg/dL). To the best of our knowledge, this is the first case of an adolescent female with anorexia nervosa and cutaneous manifestations of scurvy that resolved after the oral administration of vitamin C.

Anorexia Nervosa with Vomiting Episodes: Dermatological and Oral Complications

The aim of the study was to highlight the aspect of oral and cutaneous changes in anorexia nervosa (AN) as a purging type. On the basis of three clinical cases, a description has been made of the beginning and the possible course of the disease, teeth, oral mucosa, and skin changes resulting from the illness. The research method was based on the analysis of the available literature on AN supplemented by clinical experience of presented cases. On the basis of the interdisciplinary analysis, it was concluded that the appropriate diagnosis and treatment of AN are possible only with the collaboration of many specialists—psychiatrist or pediatric psychiatrist, general practitioner, dermatologist, dentist, and if necessary other medical specialists. In this context, psychotherapy is an integral aspect of treatment. Therefore, early intervention is essential to obtain good results of treatment.

Is hypercortisolism in anorexia nervosa detectable using hair samples?

Anorexia nervosa (AN) is a severe mental disorder accompanied by extensive metabolic and endocrine abnormalities. It has been associated with hypercortisolism using short-term measurement methods such as 24 h-urine, saliva, and blood. The aim of this study was to examine whether the proposed hypercortisolism in acutely underweight AN (acAN) is also reflected in a long-term measure: hair cortisol (HCC). To gain further insight, we compared hair cortisol to a well-established classical cortisol measure (24 h-urine; UCC) longitudinally in acAN. Hair samples were collected and analyzed using a LC-MS/MS-based method to provide a monthly cortisol value. We compared HCC in samples of 40 acAN with 40 pairwise age-matched healthy controls (HC) as well as 23 long-term recovered AN participants (recAN) with 23 pairwise age-matched HC (cross-sectional design). In the second part, UCC collected weekly during 14 weeks of weight-restoration therapy in 16 acAN was compared with the (time-corresponding) HCC using linear mixed models and bivariate correlations (longitudinal design). No group differences in HCC occurred comparing acAN and recAN to HC (cross-sectional study). The longitudinal analysis revealed a decrease of UCC but not HCC with weight gain. Furthermore, there was no overall significant association between UCC and HCC. Only in the last four weeks of weight-restoration therapy we found a significant moderate correlation between UCC and HCC. HCC did not reflect the expected hypercortisolism in acAN and did not decrease during short-term weight-restoration. Time-corresponding measurements of UCC and HCC were not consistently associated in our longitudinal analysis of acAN undergoing inpatient treatment. Given the drastic metabolic disturbances in acutely underweight AN our findings could be interpreted as disturbed cortisol incorporation or altered activity of 11-β-HSD-enzymes in the hair follicle.

Eating disorders and the skin

Eating disorders, which include anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified, are psychiatric disorders with physical complications. Several factors may contribute to the onset of anorexia nervosa and bulimia nervosa, including a familial predisposition to these disorders as well as individual personality characteristics. Dissatisfaction with body shape and an overwhelming desire to be thin are considered as risk factors for the development of eating disorders. Skin signs are the expression of the medical consequences of starvation, vomiting, abuse of drugs, such as laxatives and diuretics, and psychiatric morbidity. They include xerosis, lanugolike body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, acquired striae distensae, and acral coldness. The most characteristic cutaneous sign of vomiting is Russell sign (knuckle calluses). Symptoms due to laxative or diuretic abuse include adverse reactions to drugs. Symptoms due to psychiatric morbidity (artefacta) include the consequences of self-induced trauma. The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the "hidden" signs of eating disorders in patients who tend to minimize or deny their disorder.

Pediatric psychocutaneous disorders: a review of primary psychiatric disorders with dermatologic manifestations

Psychocutaneous disorders (PCDs) are conditions that are characterized by psychiatric and skin manifestations. Classifications of PCDs and their nomenclature are matters of debate. For the purpose of this review, we adopted the classification that distinguishes primary dermatologic disorders with psychiatric co-morbidity (PDDPC) from primary psychiatric disorders with dermatologic manifestations (PPDDM). PDDPC includes the psychophysiologic disorders such as atopic eczema, psoriasis, vitiligo, and alopecia areata. PPDDM includes impulse control disorders, obsessive-compulsive disorders, factitious disorder, factitious disorder by proxy, self-mutilation, delusions of parasitosis, psychogenic purpura/Gardner-Diamond syndrome, and cutaneous sensory disorders. Diagnosis and treatment of PCDs are challenging and require that the underlying psychopathology be addressed. A specific PCD may have different underlying psychopathologies and, at times, multiple overlapping psychopathologies may coexist. Most often, both non-pharmacologic management and psychopharmacologic treatment are necessary. The choice of psychopharmacologic agent depends on the nature of the underlying psychopathology (e.g. anxiety, depression, obsessive-compulsive disorder, psychosis). This article reviews the spectrum of PPDDM in children.

Acrocyanosis: the Flying Dutchman

Acrocyanosis is symmetric, painless, discoloration of different shades of blue in the distal parts of the body that is marked by symmetry, relative persistence of the skin color changes with aggravation by cold exposure, and frequent association with local hyperhidrosis of hands and feet. Described over a century ago and despite seeming familiarity, it remains a poorly understood condition that shares much in clinical presentation with other conditions characterized by skin color changes in the distal parts of the body. The diagnosis remains mostly clinical, and pathological mechanisms vary suggesting that acrocyanosis may not be a single entity. We performed an extensive literature review to summarize existing knowledge about the demographics, pathology, diagnosis, and treatment of this condition.

The purple digit: an algorithmic approach to diagnosis

The acute onset of purple digits is a concerning manifestation and may represent underlying, potentially life-threatening disease. Correctly identifying the etiology of purple digits is essential to proper management, and can aid in the diagnosis of systemic disease. Multiple causes of purple digits and significant overlap in clinical presentation can make diagnosis difficult. Despite the various causes of acute purple digits in the published literature, an algorithmic approach to the evaluation and management of the most common and alarming etiologies has yet to be established. The initial step in evaluating a patient with purple digits is to determine if the cause is associated with hypoxemia or trauma. If the patient is in a stable condition, the dermatologist needs to determine if the process could be related to cold exposure such as Raynaud phenomenon, acrocyanosis, pernio, cryoglobulinemia or frostbite. If the disease occurs independent of temperature, physical examination and histological evaluation of the skin is recommended. The lack of peripheral pulses are concerning for acute arterial thrombosis from peripheral vascular disease or arterial embolism. Non-blanching skin changes on the digit that lack inflammation and microthrombosis most likely represent a bleeding or platelet abnormality; however, if microthrombi are identified a more life-threatening processes such as purpura fulminans or embolic phenomenon may be occurring. Evidence of blood vessel inflammation suggests a leukocytoclastic vasculitis. The patient with a purple blanching digit and normal pulses requires an extensive historical review to help determine the cause. This review presents an algorithmic approach to assist in the evaluation and management of the purple digit.

Female adolescent hair disorders

Hair abnormalities can have tremendous psychosocial impacts on adolescents and young adults, and may cause a great amount of anxiety regarding physical appearance, associated illnesses, and potential clinical course. The pathophysiology of such disorders may vary,with potential congenital, infectious, autoimmune, nutritional, or environmental causes. Hair abnormalities may present as changes in hair appearance or quality, becoming weathered or fractured.An abnormal increase in hair is present in hypertrichosis and hirsutism, whereas a thinning or shedding of hair is evident in patients with telogen effluviumand alopecia areata. Diagnosis is focused on a detailed clinical history and physical exam, in addition to laboratory testing, a variety of clinical diagnostic tests, and scalp biopsy, which may be necessary to confirm some diagnoses. Many hair disorders have no cure, but clinicians can have a positive impact on their patients by identifying the abnormality and educating the patient regarding disease course. However, some conditions such as infectious hair disorders or scarring alopecia should be identified promptly to initiate treatment and ensure clinical improvement or optimal outcome.

Síndrome das unhas frágeis

A síndrome das unhas frágeis é queixa comum, caracterizada por aumento da fragilidade das lâminas ungueais. Afeta quase 20% da população geral, sendo mais comum em mulheres. Clinicamente se manifesta com onicosquizia e onicorrexe - distúrbios nos fatores de adesão intercelular das unhas se manifestam como a primeira, ao passo que alterações da matriz apresentamse com onicorrexe. Mesmo sendo tão usual e afetando os pacientes de maneira importante em seu cotidiano, o tratamento das unhas frágeis avançou pouco nas últimas décadas e ainda se baseia principalmente no uso da biotina.

[Skin changes and anorexia nervosa]

Anorexia nervosa (AN) is one of the most dangerous psychiatric diseases; it bears a poor prognosis, marked addictive potential and a high risk of suicide. The earlier the eating disorder is diagnosed and treated, the better the prognosis of AN. A number of dermatological conditions may be associated with AN, although none are specific for AN. These findings include xerosis cutis, effluvium, gingivitis, cheilitis, acne and nail lesions. The cutaneous findings often observed in AN may be localized to the hands ("anorectic hand"), which should therefore always be examined if AN is suspected. The diagnosis of AN can thus be facilitated by knowledge of the cutaneous manifestations, which are generally plain to see. If AN is strongly suspected, the patient should be encouraged to consult a psychiatrist/psychotherapist.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.

Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system

Brittle nail syndrome is a heterogeneous abnormality, characterized by increased fragility of the nail plate. Brittle nails affect about 20% of the population and women are affected twice as frequently as men. The vast majority of patients experience brittle nails as a significant cosmetic problem and a substantial number indicate that these nail abnormalities are painful, impair daily activities, and may have a negative impact on occupational abilities. Pathogenic factors leading to brittle nails are factors that impair intercellular adhesion of the corneocytes of the nail plate or factors that cause a pathologic nail formation by involving the matrix. Clinical features of brittle nail syndrome are onychoschizia and onychorrhexis: the impairment of intercellular adhesive factors of the nail plate is expressed as onychoschizia, whereas the involvement of the nail matrix is expressed as onychorrhexis. Although impairment of life quality has not been evaluated for patients with brittle nail syndrome, the reduction of life quality in other nail problems has been studied and is evident. A proposed scoring system of key features of brittle nails is presented, and therapeutic approaches focussed on the pathogenic factors are discussed.

Childhood body-focused behaviors and social behaviors as risk factors of eating disorders

BACKGROUND

The risk factors for adolescent eating disorders are poorly understood. It is generally agreed, however, that interactions with one's body and interactions with others are two important features in the development of anorexia and bulimia nervosa. Therefore, we assessed a variety of childhood body-focused behaviors and childhood social behaviors in eating-disordered patients as compared to non-eating-disordered subjects.

METHOD

We compared 50 female inpatients with eating disorders (anorexia or bulimia nervosa), 50 female inpatients with polysubstance dependence, and 50 nonpatient female control subjects with no history of eating or substance abuse disorders (all defined by DSM-IV criteria), using a semi-structured interview of our own design. We asked questions about (1) childhood body-focused behaviors (e.g. thumb-sucking) and body-focused family experiences (e.g. bodily caresses), and (2) childhood social behaviors (e.g. numbers of close friends) and family social styles (e.g. authoritarian upbringing).

RESULTS

Many body-focused measures, such as feeding problems, auto-aggressive behavior, lack of maternal caresses, and family taboos regarding nudity and sexuality, characterized eating-disordered patients as opposed to both comparison groups, as did several social behaviors, such as adjustment problems at school and lack of close friends. However, nail-biting, insecure parental bonding, and childhood physical and sexual abuse were equally elevated in both psychiatric groups.

CONCLUSION

It appears that eating-disordered patients, as compared to substance-dependent patients and healthy controls, show a distinct pattern of body-focused and social behaviors during childhood, characterized by self-harm, a rigid and 'body-denying' family climate, and lack of intimacy.

Medical assessment of adolescent girls with eating disorders: an evaluation of symptoms and signs of starvation

AIM

To investigate the prevalence of symptoms and signs related to starvation at the initial examination of adolescent girls with eating disorders (ED).

METHODS

Two hundred and eleven girls with eating disorders recruited for a multicentre research and evaluation programme of six specialist eating disorder services in Sweden have been studied. The presence or absence of 12 symptoms, reported by the patients, and 16 signs, observed by the examiners, were registered and related to body weight.

RESULTS

Eleven observed signs--loss of subcutaneous fat, loss of muscle mass, loss of muscular force, dry and scaly skin, brittle nails, dry and brittle hair, lanugo hair, resting pulse <60, systolic blood pressure <110, peripheral hypothermia, and peripheral cyanosis--were related to body weight expressed in standard deviation scores (SDS). When the number of observed signs for each patient was calculated, there was a strong relationship with weight. The odds ratio for having more than two signs was 4.35 (95% CI 2.67-7.04; p = 2.8 x 10(-9) for every one-unit change in weight SDS. Of the symptoms reported by the patients, only three were related to weight. When the number of reported symptoms for each patient was calculated, a relationship with weight was not observed.

CONCLUSION

In adolescent girls with ED, physical signs observed at medical examination can be related to weight. However, reported symptoms are poorly related to weight and may be influenced by other factors. The finding emphasizes the importance of medical assessment at presentation of patients with ED.

Dermatologic signs in patients with eating disorders

Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma. The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the 'hidden' signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients' distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35 microg ethinyl estradiol may improve acne in women with AN and should be given for 2-4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell's sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.

EFA supplementation in children with inattention, hyperactivity, and other disruptive behaviors

This pilot study evaluated the effects of supplementation with PUFA on blood FA composition and behavior in children with Attention-Deficit/Hyperactivity Disorder (AD/HD)-like symptoms also reporting thirst and skin problems. Fifty children were randomized to treatment groups receiving either a PUFA supplement providing a daily dose of 480 mg DHA, 80 mg EPA, 40 mg arachidonic acid (AA), 96 mg GLA, and 24 mg alpha-tocopheryl acetate, or an olive oil placebo for 4 mon of double-blind parallel treatment. Supplementation with the PUFA led to a substantial increase in the proportions of EPA, DHA, and alpha-tocopherol in the plasma phospholipids and red blood cell (RBC) total lipids, but an increase was noted in the plasma phospholipid proportions of 18:3n-3 with olive oil as well. Significant improvements in multiple outcomes (as rated by parents) were noted in both groups, but a clear benefit from PUFA supplementation for all behaviors characteristic of AD/HD was not observed. For most outcomes, improvement of the PUFA group was consistently nominally better than that of the olive oil group; but the treatment difference was significant, by secondary intent-to-treat analysis, on only 2 out of 16 outcome measures: conduct problems rated by parents (-42.7 vs. -9.9%, n = 47, P = 0.05), and attention symptoms rated by teachers (-14.8 vs. +3.4%, n = 47, P = 0.03). PUFA supplementation led to a greater number of participants showing improvement in oppositional defiant behavior from a clinical to a nonclinical range compared with olive oil supplementation (8 out of 12 vs. 3 out of 11, n = 33, P = 0.02). Also, significant correlations were observed when comparing the magnitude of change between increasing proportions of EPA in the RBC and decreasing disruptive behavior as assessed by the Abbreviated Symptom Questionnaire (ASQ) for parents (r = -0.38, n = 31, P < 0.05), and for EPA and DHA in the RBC and the teachers' Disruptive Behavior Disorders (DBD) Rating Scale for Attention (r = -0.49, n = 24, P < 0.05). Interestingly, significant correlations were observed between the magnitude of increase in alpha-tocopherol concentrations in the RBC and a decrease in scores for all four subscales of the teachers' DBD (Hyperactivity, r = -0.45; Attention, r= -0.60; Conduct, r = -0.41; Oppositional/Defiant Disorder, r = -0.54; n = 24, P < 0.05) as well as the ASQ for teachers (r = -0.51, n = 24, P < 0.05). Thus, the results of this pilot study suggest the need for further research with both n-3 FA and vitamin E in children with behavioral disorders.

Microcirculatory assessment of vascular acrosyndrome in anorexia nervosa and analysis of manifestation factors

OBJECTIVE

Acrocyanosis (AC) is a common manifestation of starving syndrome in anorexia nervosa. We characterized microvascular changes associated with AC and determined discriminating factors between acrally symptomatic and nonsymptomatic patients.

METHODS

We examined 34 patients with anorexia nervosa (15 restrictive-anorectic type, 19 binge-eating/purging type, duration 1-25 years). Nineteen were symptomatic (SP) and 15 were nonsymptomatic (NSP). All underwent photo-pletysmography, sonography of the brachial artery, capillary microscopy and laboratory analysis.

RESULTS

Disease characteristics and body mass index did not differ between SP and NSP. In SP more dilated efferent capillary loops and venoles were present (P<.001) and capillary flow velocities were reduced (0.21+/-0.12 ml/min vs. 0.34+/-0.15 ml/min; P=.015). Flow-mediated and nitroglycerin-induced dilatation showed no differences. Symptomatic patients had lower leukocyte counts (P=.008), lower eosinophils (P=.003) and lower LDL (P=.045) concentrations. A logistic regression model identified only leukocytes (P=.017) and eosinophils (P=.023) to be associated with AC.

CONCLUSIONS

In acrally symptomatic patients the typical microvascular features of AC are present. AC is associated with lower leukocyte counts and lower eosinophils.

Psychodynamics of onychophagists

The authors offer three interpretations of onychophagia, a widespread but largely unstudied phenomenon. The first is phenomenological, and characterises onychophagia as a non-pathological behavioural symptom present in many pathologies and a distinct syndrome that is sometimes quite severe. The second is clinical, and indicates the convergent and divergent connections between onychophagia and the most frequent eating disorders. The third is psychodynamic, and suggests an interpretative hypothesis of onychophagia itself and the frequent sensation of trouble and refusal that it often provokes even in doctors and psychotherapists.

Cutaneous manifestations of eating disorders

BACKGROUND AND OBJECTIVE

No complete review of the cutaneous manifestations of eating disorders exists. We therefore, set out to review and systematically describe the clinical and histopathologic features of dermatologic conditions associated with anorexia nervosa, bulimia nervosa, and obesity. Differential diagnosis, pathophysiology, laboratory studies, and treatment are also reviewed.

METHODS

Index Medicus review (1966 to present) using Ovid-MEDLINE. Search terms included eating disorders, anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified (ED-NOS), and obesity, as well as the terms dermatology skin and cutaneous manifestations, with cross-referencing sources. These were combined with our own clinical experience. All relevant publications, including case reports, case series, cohort studies, and histopathologic studies giving at least Level II-3 evidence (evidence from comparisons between times or places with or without the intervention, including dramatic results in uncontrolled experiments), were selected.

CONCLUSION

Forty dermatological signs have been reported in eating disorder patients. Eating disorders have many cutaneous manifestations and cutaneous signs may lead to the diagnosis of an occult eating disorder. The resolution of skin eruptions in eating disorder patients often depends on treatment of the underlying disorder.

Bulimia and anorexia nervosa: cutaneous manifestations

Bulimia and anorexia nervosa (BN, AN) are considered psychiatric disorders that have physical complications. Several factors may play a role in the onset of AN and BN, including a familial predisposition to these disorders, as well as individual personality characteristics. Dissatisfaction with body shape and an overwhelming desire to be thin are considered as risk factors for the development of eating disorders. Skin changes are characteristic and are cardinal diagnostic symptoms and pointers to the diagnosis of eating disorders. They are a consequence of starvation and/or malnutrition, self-induced vomiting, drug consumption and concomitant psychiatric illness. A careful examination of the skin can suggest a diagnosis of eating disorder. Cosmetic dermatologists, whose patients are mostly women, have a unique opportunity to detect these signs. This is very important as an early diagnosis will influence prognosis.

Bulimia in children and adolescents

Although there have been many recent advances in research, much work remains to be done in the area of child and adolescent eating disorders. More data are needed regarding the normal development of eating behavior, resilience and risk factors for eating pathology, and treatment studies in children and adolescents. The best studied areas include epidemiology, short-term treatment for bulimia nervosa (BN), and outcome in anorexia nervosa. A case report of the single blind use of repetitive transcranial magnetic stimulation in a patient with BN has been reported, but its safe use in children and adolescents remains to be established.

Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls

BACKGROUND

We have recently observed that women with the eating disorders (EDs) anorexia nervosa and bulimia nervosa report a significantly greater (P = 0.002) dissatisfaction with the appearance of their skin than do non-clinical controls.

OBJECTIVES

To examine further the nature of the dissatisfaction with skin appearance in women with EDs.

METHODS

Several psychosocial and body image parameters, including whether or not the subjects were satisfied with a wide range of attributes associated with non-diseased skin, were surveyed in women aged < or = 30 years. Survey data from 32 women with EDs and 34 randomly selected community-based non-clinical controls were examined.

RESULTS

Eighty-one per cent of the patients with EDs vs. 56% of the controls reported dissatisfaction with the appearance of their skin (P = 0.03), particularly with respect to its dryness and roughness. Other attributes that were rated more frequently were 'bags' and 'darkness' under the eyes, freckles, fine wrinkles and patchy hyperpigmentation.

CONCLUSIONS

There is a high prevalence of dissatisfaction with skin appearance among women aged < or = 30 years, which is even higher among patients with EDs.