Cutaneous manifestations of nutritional deficiency

Preparing Patients for Cosmetic Surgery and Aesthetic Procedures: Ensuring an Optimal Nutritional Status for Successful Results

Aesthetic and cosmetic medical practices have attracted considerable consumer attention globally. However, possible complications vary and range from mild, self-resolving ecchymoses or edema to more persistent complications. The aim of this review is to identify the nutritional deficits or excesses associated with the major complications of reconstructive surgery, aesthetic surgery, and mini-invasive aesthetic procedures. An additional goal is to provide a bundle of actions for professionals working in the industry in order to reduce the risks of aesthetic procedures and improve the clinical outcomes. Granulomas, hypertrophic scars and keloids, seromas, infections and xerosis, hyperpigmentation, petechiae, livedo reticularis, slower wound healing, and other poor outcomes are frequently associated with nutritional deficiencies. Nutritional status can markedly affect wound healing and tissue repair following surgical interventions, as well as the outcomes of aesthetic and cosmetic medical practices. Professionals working in this industry, therefore, need to consider the nutritional aspects of their patients to obtain the best results.

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.

Deleterious side effects of nutritional supplements

Vitamin and mineral supplement consumption is widespread. They are taken for a variety of conditions, including dermatologic disorders. Although consumers often assume these supplements are safe, excessive consumption of supplements may have deleterious effects. Such vitamin supplements include vitamin A, niacin, biotin, vitamin D, and vitamin E, and specific mineral supplements include zinc, copper, and iron. These supplements may have a number of potential adverse effects.

Effect of Vitamin-Containing Amino Acid Supplements on Menopausal Symptoms and Age-Related Skin Changes: A Randomised, Double-Blind, Placebo-Controlled Study

Introduction

Women aged ≥  45 years are known to experience various menopausal symptoms due to reduced oestrogen levels. Changes associated with cutaneous ageing, such as wrinkles and sagging, are also prominent in women in this age group. Numerous studies have evaluated the usefulness of individual basic nutrients and essential components, such as amino acids and vitamins, in menopausal women. The aim of this study was to comprehensively assess the effects of supplements containing amino acid and vitamin combinations on menopausal symptoms and age-related changes in the skin.

Methods

This is a randomised, placebo-controlled study on the effects of a supplement containing three types of amino acids [leucine, glutamine and arginine (LGA)] and 11 types of vitamins in 37 middle-aged women. The participants ingested either the test substance or a placebo twice daily for 8 consecutive weeks, at the end of which time the efficacy and safety of the test substance were assessed based on subjective symptoms of fatigue, Simplified Menopausal Index (SMI) score, the grade and number of wrinkles at the corners of the eyes, results of an analysis of the stratum corneum of the cheek and blood test results.

Results

None of the participants experienced adverse events, and all items assessed in our survey of subjective symptoms of fatigue showed a significant decrease in the test substance group (LGA group). Additionally, the SMI score of the LGA group was significantly lower than that of the placebo group. The LGA group showed significant improvement in the grade of the wrinkles in the corners of the eyes and the number of wrinkles, and the stratum corneum cell area declined significantly in the LGA group compared to the placebo group at the end of the study.

Conclusion

These results indicate that the vitamin-containing amino acid supplement improved menopausal symptoms and age-related changes in the skin (wrinkles).

Trial Registration

UMIN000029830.

Relationship between Trace Elements and Premature Hair Graying

Context:

Hair is said to gray prematurely when a minimum of five gray hairs occurs before the age of 20 in fair skinned, 25 in Asians, and 30 in Africans. It may be genetically associated with autoimmune syndromes or certain environmental factors.

Aims:

The aim of this study was to evaluate the serum level of iron, copper, and calcium and to assess their role in premature hair graying.

Subjects and Methods:

This study was carried out on 60 patients with premature hair graying (PHG) and 30 age- and sex-matched healthy individuals served as a control group. The severity of PHG was assessed by the hair whitening scoring system. Serum iron, copper, and calcium concentrations were measured using Beckman Coulter instrument and spectrophotometric method.

Results:

There was a reduction in serum levels of iron, copper, and calcium in patients with PHG in comparison with controls. There was a statistically negative significant correlation between the severity of PHG and serum iron and calcium levels. There was a negative nonsignificant correlation between body mass index and serum iron, copper, and calcium levels.

Conclusions:

Serum iron, copper, and calcium levels were reduced in association with PHG and correlated with its severity. Premature graying may be an indicator that hair is not getting enough nutrients and minerals, and supplementation with these trace elements might reverse and is expected to prevent progression of canities; however, further studies are needed to find the underlying mechanism of this relationship.

Dermatologic findings of vitamin B12 deficiency in infants

BACKGROUND/OBJECTIVES

Vitamin B₁₂ deficiency in infants is uncommonly reported from developed countries and generally lacks dermatologic manifestations. On the contrary, infantile vitamin B₁₂ deficiency is common in India and cutaneous manifestations are a constant feature, although often overshadowed by neurologic and hematological manifestations. The aim of this study was to describe the skin changes of vitamin B₁₂ deficiency in infants.

MATERIALS AND METHODS

A retrospective chart review of vitamin B₁₂ deficient infants for clinical and laboratory parameters was performed and data analyzed.

RESULTS

Forty-three infants, 30 boys and 13 girls, aged 4 to 27 months, with vitamin B₁₂ deficiency were identified. Skin hyperpigmentation was present in 41 infants; it was localized to the dorsa of hands and feet in 26. Fifteen infants had generalized hyperpigmentation; 10 had a reticulate pattern, and 5 had a homogeneous pattern. Brown and sparse scalp hair were present in all. Glossitis was seen in 5 infants and cheilitis in 3. Of the 32 infants who underwent laboratory investigations, 28 had anemia and 21 macrocytosis. Serum vitamin B₁₂ was measured in 30 infants; it was low in 19. Of the 11 with normal serum vitamin B₁₂ , 9 had received vitamin B₁₂ before referral but had macrocytosis and low maternal serum vitamin B₁₂ . The infants were treated with vitamin B₁₂ . Skin pigmentation and mucosal changes resolved completely by 3-4 weeks, but hair changes were slower to reverse.

CONCLUSION

Cutaneous findings are a common feature of vitamin B₁₂ deficiency in Indian infants and resolve with treatment.

Impact of Childhood Malnutrition on Host Defense and Infection

The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.

Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE)

An increasing recognition has emerged of the complexities of the global health agenda—specifically, the collision of infections and noncommunicable diseases and the dual burden of over- and undernutrition. Of particular practical concern are both 1) the need for a better understanding of the bidirectional relations between nutritional status and the development and function of the immune and inflammatory response and 2) the specific impact of the inflammatory response on the selection, use, and interpretation of nutrient biomarkers. The goal of the Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE) is to provide guidance for those users represented by the global food and nutrition enterprise. These include researchers (bench and clinical), clinicians providing care/treatment, those developing and evaluating programs/interventions at scale, and those responsible for generating evidence-based policy. The INSPIRE process included convening 5 thematic working groups (WGs) charged with developing summary reports around the following issues: 1) basic overview of the interactions between nutrition, immune function, and the inflammatory response; 2) examination of the evidence regarding the impact of nutrition on immune function and inflammation; 3) evaluation of the impact of inflammation and clinical conditions (acute and chronic) on nutrition; 4) examination of existing and potential new approaches to account for the impact of inflammation on biomarker interpretation and use; and 5) the presentation of new approaches to the study of these relations. Each WG was tasked with synthesizing a summary of the evidence for each of these topics and delineating the remaining gaps in our knowledge. This review consists of a summary of the INSPIRE workshop and the WG deliberations.

The melanocyte lineage in development and disease

Melanocyte development provides an excellent model for studying more complex developmental processes. Melanocytes have an apparently simple aetiology, differentiating from the neural crest and migrating through the developing embryo to specific locations within the skin and hair follicles, and to other sites in the body. The study of pigmentation mutations in the mouse provided the initial key to identifying the genes and proteins involved in melanocyte development. In addition, work on chicken has provided important embryological and molecular insights, whereas studies in zebrafish have allowed live imaging as well as genetic and transgenic approaches. This cross-species approach is powerful and, as we review here, has resulted in a detailed understanding of melanocyte development and differentiation, melanocyte stem cells and the role of the melanocyte lineage in diseases such as melanoma.

Summary: This Review discusses melanocyte development and differentiation, melanocyte stem cells, and the role of the melanocyte lineage in diseases such as melanoma.

Nutrition-focused physical examination in pediatric patients

A complete nutrition assessment includes several components: medical record review, anthropometric measurements, diet/nutrition intake, interview, and physical examination. The nutrition-focused physical examination (NFPE) can identify or confirm muscle wasting, subcutaneous fat loss, and edema and clarify information gathered during the medical record review. The physical examination component of the nutrition assessment is more critical in pediatric patients because pediatric patients can become malnourished more quickly than adults and because prolonged malnutrition can negatively affect growth and development. In addition, case studies of micronutrient deficiencies, essential fatty acid deficiency, and protein-calorie malnutrition with skin manifestations have been reported in developed countries. The etiologies of the deficiencies are chronic disease, long-term tube feedings, or long-term parenteral nutrition. An NFPE involves an in-depth examination of the patient from head to toe by a trained nutrition professional. Nutrition professionals recognize the importance and value of an NFPE, yet it is seldom completed, particularly in pediatrics, most likely due to lack of training and lack of pediatric-specific information or training opportunities. Although there are similarities between NFPE in pediatric and adult patients such as the techniques used (inspection, palpation, percussion, and auscultation), there are important differences related to growth and development. This review provides an overview of nutrition assessment with focus on the NFPE and aspects unique to the pediatric patient.

Dermatologic conditions in internationally adopted children

Over 200,000 children have been adopted into United States (US) families from abroad since the year 2000. Health care providers who care for children adopted internationally should be aware of the spectrum of illnesses seen in this population, and should be prepared to encounter potentially unusual situations. An appreciation for the unique pre-adoption exposures and vulnerabilities inherent in international adoption is critical for proper diagnosis and treatment of this heterogeneous group of children. It is important to consider the impact of potential early childhood stressors such as nutritional, sensory, and emotional deprivation, trauma and abuse, as well as prenatal exposures to drugs, alcohol, and infectious diseases. Providers must also take into account international variation in health care practices, including immunization, treatment, surgical, and hygiene standards. The differential diagnosis for cutaneous eruptions in children adopted internationally is broad and must encompass endemic systemic illnesses with skin manifestations, such as measles, tuberculosis, leprosy, and congenital syphilis, and primary dermatologic diseases such as scabies and bacterial and fungal infections. The importance of maintaining a broad differential and open mind when addressing the dermatologic needs of these children cannot be overemphasized.

•

Dermatologists caring for children adopted internationally should be prepared for unusual situations.

•

It is important to consider potential iatrogenic and infectious exposures, early physical and psychosocial stressors, and international variation in health care practices.

•

The importance of maintaining a broad differential and open mind in these cases cannot be overemphasized.

Scurvy: a new problem for patients with chronic GVHD involving mucous membranes; an easy problem to resolve

Vitamin C deficiency in developed countries is typically observed in patients with unique clinical conditions such as cystic fibrosis or anorexia nervosa, or in patients on long-term tube feeds. We report here a clinical observation in six pediatric and adolescent patients (median age 17.5 yr, range 9.8-23.5 yr) with chronic GVHD with mucous membrane involvement found to be vitamin C deficient. These patients' baseline serum vitamin C levels ranged from <0.12 to 0.94 mg/dL (normal value 0.20-1.90 mg/dL), with a mean level 0.56 ± 0.36 mg/dL and a median level 0.6 mg/dL. Among these patients, signs and symptoms of mucositis failed to respond to standard chronic GVHD therapy. After receiving treatment with 2000 mg of ascorbic acid by mouth, daily patients displayed increased serum vitamin C levels. Clinically, this correlated with a remarkable improvement in patients' mucositis and ability to eat.

Dermatological complications after bariatric surgery: report of two cases and review of the literature

Bariatric surgery aims at weight reduction of severely obese patients. The Roux-en-Y technique is one of the most common bariatric procedures and is occasionally accompanied by nutrient insufficiencies and metabolic changes. According to the literature, skin architecture and immunity change after bariatric surgery and may lead to inflammation and increased susceptibility to pathogens. Additionally, vitamin and mineral deficiencies frequently develop in these patients and affect the skin's defense mechanisms, possibly contributing to dermatological complications. Knowledge and recognition of skin changes after bariatric surgery make an important asset for the dermatologist and help in the proper treatment of these patients. We report 2 cases of infectious skin lesions where vitamin and trace element deficiencies have possibly contributed to their persistence and resistance to traditional treatments.

Epidemiological and investigative study of premature graying of hair in higher secondary and pre-university school children

BACKGROUND

Hair pigmentation is one of the most conspicuous phenotypes in humans ranging from black, brown, and blonde to red. Premature graying of hair occurs more commonly without any underlying pathology but is said to be inherited in autosomal dominant pattern. Premature graying has been shown to be associated with a few of the autoimmune disorders. A role for environmental factors and nutritional deficiencies has also been postulated. However, to date the exact etiology of premature graying has not been established.

AIM

The objective of our study was to conduct an epidemiological and investigative study of premature graying of hair in higher secondary and pre-university school children of the semi-urban area.

MATERIALS AND METHODS

A total of 35 cases and controls were investigated for various parameter such as Hemoglobin, total iron binding capacity, serum ferritin (S. Ferritin), serum calcium (S. Ca), serum iron (S. Iron), vitamin B12, and vitamin D3 after taking informed consent. Epidemiological and investigations correlation was established using the Chi-square and Mann Whitney test and P < 0.05 values were considered significant.

RESULT

Among the various laboratory parameters S. Ca, S. Ferritin and vitamin D3 were low in patients with premature graying of hair. There was significant high number of vitamin D3 deficient and insufficient among the cases compared to the controls.

CONCLUSION

According to our study S. Ca, S. Ferritin, vitamin D3 may play a role in premature graying of hair in our society.

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.

Serum iron, zinc, and copper concentration in premature graying of hair

Premature graying of hair with unclear etiology, which is known as premature canities, is a common cause of referrals to the dermatologists. We assessed the relationship between serum iron, copper, and zinc concentrations with premature canities. This study was conducted on patients under 20 years old suffering from premature canities, having a minimum of ten gray hair fibers, and referring to university hospitals of Isfahan (Iran). The results were compared with age-sex-matched controls. Demographic data and disease characteristics were recorded for two groups. We studied serum iron, copper, and zinc concentrations of 66 patients and 66 controls using atomic absorption and Ferrozine methods. The mean age of studied cases was 17.8 ± 2.0 years, and the mean age of the onset of canities was 15.5 ± 3.2 years with no significant difference between males and females (P > 0.05). Serum copper concentration was significantly lower in patients compared with controls (90.7 ± 37.4 vs. 105.3 ± 50.2 μg/dL, P = 0.048), but serum iron concentration was significantly lower in controls compared to patients (88.8 ± 39.5 vs. 108.3 ± 48.4 μg/dL, P = 0.008). Also, there was no significant difference between patients and controls in serum zinc concentration (114.8 ± 67.8 vs. 108.2 ± 49.9 μg/dL, P = 0.285). According to these results, among copper, zinc, and iron, a low serum copper concentration may play a role in premature graying of hairs in our society. Further studies are needed to find the underlying mechanism of this relationship.

Diversity of human hair pigmentation as studied by chemical analysis of eumelanin and pheomelanin

Hair colour is one of the most conspicuous phenotypes in humans, ranging from black, brown, blond to red. This diversity arises mostly from the quantity and ratio of the black-dark brown eumelanin and the reddish-brown pheomelanin. To study the chemical basis underlying the diversity of hair colour, we have developed several chemical methods to quantify those two pigments. Alkaline H(2) O(2) oxidation affords pyrrole-2,3,5-tricarboxylic acid (PTCA) as a eumelanin marker and thiazole-2,4,5-tricarboxylic acid (TTCA) as a pheomelanin marker. Pheomelanin can also be analysed as 4-amino-3-hydroxyphenylalanine (4-AHP) after hydroiodic acid hydrolysis. Using those methods, we evaluated the contents of eumelanin and pheomelanin (the 'chemical' phenotype) in human hairs of black, dark brown, brown, light brown, blond and red colour (the 'visual' phenotype). Eumelanin contents decrease in that order, with a trace but constant level of pheomelanin, except for red hair which contains about equal levels of pheomelanin and eumelanin. Thus, the chemical phenotype correlates well with the visual phenotype. The genotype of melanocortin-1 receptor (MC1R), a gene regulating the red hair phenotype, is predictive of hair melanin expressed as the log value of eumelanin to pheomelanin ratio, with a dosage effect evident. Hair melanin contents were also analysed in patients with various hypopigmentary disorders including Hermansky-Pudlak syndrome, Menkes disease, proopiomelanocortin deficiency, cystinosis, malnutrition and trace metal deficiency. The chemical phenotype helped evaluate the precise effects of each disease on pigmentation. In studies of human hair, the chemical phenotype will find more and more application as an objective measure of pigmentation.

Unusual case of relapsing and remitting rash with progressive motor sensory neuropathy and spinal cord atrophy

The authors report a case of a 7-year-old girl with a progressive sensorimotor peripheral neuropathy with acute relapses associated with a desquamating purpuric rash, alopecia, and spinal cord atrophy. Distinctive features include systemic involvement with alopecia and rash, peripheral nervous system involvement with relapsing and remitting sensorimotor neuropathy, and central nervous system involvement with episodes of dystonic posturing and spinal cord atrophy. Extensive diagnostic evaluation for known causes of skin manifestations associated with peripheral neuropathy has failed to identify a cause for this patient's condition. The authors discuss the case as an approach to the differential diagnosis and to highlight unusual features of this yet to be identified clinical entity.

Infancy- and childhood-onset dyschromatoses

The dyschromatoses are a group of pigmentary disorders characterized clinically by mixed and often guttate hypopigmented and hyperpigmented lesions. There are many conditions that present with dyschromatosis, including genodermatoses, inflammatory skin diseases, infections, drug and chemical use, and nutritional disorders. Some conditions have extracutaneous features. Poikiloderma (a combination of hypo- and hyperpigmentation with telangiectasia and atrophy) must be excluded. In this article, we describe the dyschromatoses typically presenting in infancy and childhood, most of which are genodermatoses. The approach we have taken in classifying them is based on organ involvement. We hope this article will serve as a guide for dermatologists to the recognition of these uncommon conditions.

Cobalamin status in children

Cobalamin and the metabolic markers methylmalonic acid and total homocysteine undergo marked changes during childhood. In breastfed infants a metabolic profile indicative of cobalamin deficiency is common. Symptoms of cobalamin deficiency in children differ with age, presenting a continuum from subtle developmental delay to life-threatening clinical conditions. The symptoms may be difficult to detect, particularly in infants, and there tends to be a diagnostic delay of several months in this age group. Several reports show that even moderate deficiency in children may be harmful, and long-term consequences of neurological deterioration may persist after cobalamin deficiency has been treated. Given the crucial role of cobalamin for normal growth and development, possible widespread infantile deficiency needs attention. Cobalamin deficiency should be considered a differential diagnosis in children with subtle symptoms, and strategies to prevent cobalamin deficiency in mothers and children should be addressed.

Hair loss in long-term or home parenteral nutrition: are micronutrient deficiencies to blame?

PURPOSE OF REVIEW

To review the key nutritional factors associated with hair loss in long-term parenteral nutrition patients.

RECENT FINDINGS

The phenomenon of unexplained hair loss is multifactorial, and nonstandard definitions are applied. Deficiencies of essential fatty acids resulting in alopecia and other symptoms appear to have been eliminated by regular use of lipid-containing parenteral nutrition. Zinc is the most frequently suspected deficiency with rapid clinical responses reported from zinc therapy. Alopecia in some infants on parenteral nutrition has been relieved in a few weeks by selenium supplementation as selenite. There may be a relationship between iron depletion and diffuse hair loss in home parenteral nutrition patients at higher risk of anaemia. A serum ferritin level of 70 μg/l should be targeted when hair loss is unexplained. However, there is limited data correlating cessation of hair loss with iron therapy and insufficient evidence to recommend iron supplementation in patients without anaemia. Parenteral nutrition-associated biotin deficiency has not been reported since the vitamin has been routinely added to parenteral nutrition. However, marginal biotin status, associated with diffuse hair loss, could still be prevalent.

SUMMARY

Micronutrient status is infrequently monitored and current recommendations for supplementation are nonspecific for hair loss in long-term parenteral nutrition. Studies are required to determine the incidence of marginal zinc, selenium, iron or biotin deficiencies that could manifest as hair loss.