1 / 61

Nutritional Dermatoses

Nutritional Dermatoses. Stages of nutritional deficiency syndrome. Stage I Intake falls below daily requirement but the reserves maintain normal blood values Stage II Blood levels decrease but patient is asymptomatic Stage III

Download Presentation

Nutritional Dermatoses

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Nutritional Dermatoses

  2. Stages of nutritional deficiency syndrome • Stage I Intake falls below daily requirement but the reserves maintain normal blood values • Stage II Blood levels decrease but patient is asymptomatic • Stage III Development of clinical signs and symptoms

  3. Causes of deficiencies • Increased requirement • During growth • Pregnancy • Lactation • Fever • Hyperthyroidism Decreased intake • Poverty • Ignorance • Food faddism • Crash diets • Anorexia nervosa

  4. Stages of nutritional deficiency syndrome Decreased absorption and utilization • GI - mucosal disturbances: Malabsorption syndrome • Dietary factors: High dietary phytate, TPN, alcoholism • Trauma: Burns , Post surgical procedures • Malignancy • Renal disorders • Infections: Parasitic, bacterial, viral • Miscellaneous: Collagen vascular disease, HIV

  5. Nutritional deficiencies • Fat soluble vitamins (A,D,E,K) • Water soluble vitamins (B-complex, Niacin, Pantothenic acid, Biotin, Vit C) • Minerals • Trace elements (Zinc, Iron) • Essential fatty acids (EFA) • PEM (Protein energy malnutrition)

  6. Important Points 1. Water soluble vitamins • Not stored in body • Excessive consumption No toxicity 2. Fat soluble vitamins (A, D, E, K) • Stored in liver • Excessive consumption toxicity

  7. Vitamin A (Retinol) deficiency Rich source • Animal fats, fish liver oils, milk, butter, eggs, liver , kidneys Provitamin A (Beta carotene) • Green and yellow parts of plants (spinach, drum sticks, spring onions, cabbage, pumpkin, carrots, tomato) • Fruits – mango, papaya

  8. Clinical features Skin manifestations: • Infants, very young children Extensive xerosis - an earliest manifestation • Adults: Follicular hyperkeratosis • Sites: extensor of extremities; spreads to shoulder, face, chest, abdomen, back , buttocks. Dry, firm brown follicular papule with keratotic plug covered with loosely adherent scale On removal of plug, a pit is seen

  9. Clinical features Skin manifestations: • Phrynoderma (Toad skin) Mild follicular hyperkeratosis, limited distribution • Mixed deficiencies of Vit.A, Vit.E, B - complex, Vit.C and EFA

  10. Clinical features Eye Manifestations: Common cause of blindness in developing countries • Earliest symptoms: • Nyctalopia (night blindness) • Hemeralopia (inability to see bright light) • Xerophthalmia: • Conjunctivalxerosis • Bitot’s spot • Corneal xerosis • Corneal ulceration • Keratomalacia • Phthisis bulbi, scarring, blindness

  11. Treatment Normal requirements: • Infants, children < 4 yrs - 1500 IU of Vit. A > 4 yrs - 5000 IU of Vit. A Prophylactic Treatment: • Vit. A (2 lacs IU) every 6 months to pre-school children (Orally retinylpalmitate in oil) • Good quality protein diet + vitamins • Education of local community Contd…

  12. Treatment • Dose of 1-3 lacs IU of Vit. A for 1-3 days (Stop in case of headaches) • Supplements: Vit. B complex and EFAs • Diet to include eggs, milk, butter, green leafy vegetables • Treatment of underlying cause (especially protein and zinc deficiency)

  13. Vitamin D • Vit. D is a group of antirachitic sterol derivatives, considered as a hormone • Skin: Role in synthesis, storage and release of Vit. D

  14. Source of Vit. D and Chemistry • Plants ergosterolergocalciferol (Vit D2) • Animal and dairy products (Eggs, liver, butter, codliver oil) 7 dehydrocholesterol (human skin) UVB Cholecalciferol (Vit. D3) Liver 25 hydroxycholecalciferol Kidney 1, 25 di-hydroxycholecalciferol (Calcitriol)

  15. Clinical features and treatment Children: • Rickets, Tetany Adults: • Osteomalacia • Type I Vit.D dependent rickets : No skin lesions • Type II Vit.D resistant rickets : Progressive alopecia Treatment: • Normal daily requirement: 400 IU • In rickets : 5000 IU oral Vit D for 3 to 5 weeks • Exposure to sunlight

  16. Vitamin B Complex • Mostly combined deficiencies occur due to insufficient proteins or other essential nutrients (Zinc, EFA)

  17. Vitamin B1 (Thiamine, Aneurin) Sources • Yeast (richest source), unmilled cereals, pulses, nuts Beriberi Dry • Peripheral neurologic syndrome, atrophic skin, red burning tongue • Korsakoff'spsychosis,Wernicke's encephalopathy Beriberi Wet • High output cardiac failure Skin is warm before CCF and cold, edematous, cracked later

  18. Diagnosis and treatment Diagnosis • Urinary excretion of < 50 mcg of thiamine after 1 mg injection Treatment: • Dietary requirement - 0.5 mg /1000 kcal, 0.5 to 2 mg • Beriberi - 10 to 100 mg / day • If severe - add manganese (corrects thiamine resistance) • B - complex vitamins are supplemented • Local application of zinc oxide ointment , mineral oil (for cracked skin)

  19. Riboflavin deficiency (Vit. B2): (Oro - Oculo - Genital syndrome) Sources of Vit. B2: • Milk, milk products, eggs, liver, cereals, pulses, green leafy vegetables • Deficiency of Vit.B2 affects metabolism of free fatty acids, tryptophan, folic acid • Presents as overlapping manifestations

  20. Clinical features • Seen after 3-5 months of inadequate diet It is also known as “pellagra sine pellagra” • Oral manifestations: • Angular stomatitis (perleche) with candidiasis • Cheilosis : lip involvement with vertical fissuring • Glossitis : magenta coloured tongue atrophic filiform papillae enlarged fungiform papillae

  21. Clinical features Skin manifestations: • Seborrheic dermatitis like rash; dyssebacea Fine greasy scales with erythema over nasolabial folds, ala nasi, nasal bridge, forehead, eyelids, earlobes • Dysriboflavinosis Dyskeratotic follicular papules with scaly erythema • Patchy alopecia with scaling on scalp and eyebrows

  22. Clinical features • Genitals: Earliest manifestation (scrotum, vulva) Early - Patchy redness, fine powdery desquamation Late - Lichenification Severe - Raw areas over shaft of penis, inner thighs • Eyes: Photophobia, lacrimation, blepharospasm, conjunctivitis, decrease in visual acuity, corneal vascularization • CNS: Psychomotor, intellectual development impaired in children

  23. Diagnosis and treatment Diagnosis • Urinary excretion < 30 mcg of vit.B2 / gm of creatinine Treatment: • Normal requirement : 1-2 mg / day mg • Therapeutic dose: Infants : 1-3 mg Adults : 10-30 mg • Correct the associated tryptophan, FA, EFA deficiency

  24. Vitamin B3 (Nicotinic acid, Nicotinamide, Niacin ) Pellagra (deficiency of Niacin) • Italian word pelle - skin, agra - rough • First described in 1735 by Casal in Spain • Niacin includes both nicotinic acid and niacinamide • Niacinamide is active form and is converted to coenzymes NAD, NADP • Plays a vital role in cell, fatty acid, carbohydrate metabolism

  25. Sources • Meat, fish, eggs • Milk, cheese • Cereals, grains, legumes • Coffee and tea • Endogenous production 60 mg of tryptophan 1mg of niacin

  26. Etiology • Staple diet of maize and jowar with less animal proteins • Maize - poor source of nicotinic acid and tryptophan - niacin is present but not bio-available • Jowar - high content of leucine Imbalance in leucine and isoleucine inhibition of NAD Tryptophan Niacin • Chronic alcoholics - unbalanced diet • Malabsorption

  27. Clinical features • This disease is characterized by 4 “D’s” • Dermatitis • Dementia • Diarrhea • Death • Prodrome - weakness, fatigue

  28. Clinical features Skin: • Photo exposed areas • Erythema - well demarcated patches with pruritus and burning, slight edema • Blisters, dry brown scales • Pressure sites, shoulder, elbow, buttocks, knee • Intertriginous area - redness, maceration

  29. Clinical features • Pellagrins nose Dull erythema, butterfly rash with scaling on bridge of nose • Casal's necklace Sharply demarcated lesion on upper central chest, neck • Cravat Anterior continuation of necklace on chest • Scrotal erythema Symmetrical lesions, clear line of demarcation

  30. Clinical features • Mucous membrane • Angular stomatitis, cheilitis • Scarlet glossitis with imprint of teeth • Tongue is red, smooth, atrophy of filiform papillae, erosions, ulcerations, fissures • Swelling of parotid gland, increased salivation • GIT: Anorexia, nausea, vomiting, abdominal pain, bloody diarrhoea • CNS: Depression, psychosis

  31. Treatment Daily requirement - 10 to 20 mg / day Therapeutic dose: • 300 - 500 mg niacinamide orally or intramuscular in divided doses (amide preferred because it does not precipitate flushing, itching, burning) • Supplement with B complex, animal proteins eggs, milk • Balanced diet • Reduce alcohol

  32. Vitamin B6 deficiency (Pyridoxine) • Animal sources: Liver, egg yolk, meat • Vegetable sources: Pulses, cereals, peas, soya beans • Pyridoxine deficiency occurs during administration of drugs like: INH Hydralazine Cycloserine Penicillamine

  33. Clinical features • Children: convulsion, anemia • Adults: seborrheic dermatitis like rash, cheilitis, angular stomatitis, glossitis, peripheral neuritis • Chinese restaurant syndrome : (Inability to metabolize monosodium glutamate) Headache, sensation of pressure in chest, palpitation, feeling of warmth, tingling, numbness

  34. Diagnosis and treatment Diagnosis • Serum Pyridoxal phosphate levels < 20 mcg / ml Treatment: • Daily requirement: 1.5 - 2.5 mg • Therapeutic dose: 30 -100 mg / day orally

  35. Vit B12 deficiency (Cobalamin, Cyanocobalamin) • Sources: • Liver, kidney, heart - richest • Meat, fish, cheese, eggs, milk • Vegetables, fruits, legumes - nil; but present if contaminated by bacteria • Vit B12 is synthesized in colon (low bio-availability)

  36. Cause of deficiency of Vit.B12 • Strict vegetarian diet • Gastric atrophy (achlorhydria) and decreased intrinsic factor (pernicious anemia) • Diphyllobothriumlatuminfestation • Malabsorption syndromes (sprue, intestinal TB, Whipple’s disease) • Elderly individuals, chronic alcoholism

  37. Clinical features • Skin Symmetrical generalized hyperpigmentation (greyish - brown) • Mucous membrane Hyperpigmentation, cheilitis, glossitis with beefy red tongue, glossodynia, aphthae like lesions • Nails: Pigmented streaks • Hair: Premature graying, canities • Other manifestations: Megaloblastic, pernicious anemia, peripheral neuritis, poor memory

  38. Diagnosis • Serum Vit. B12 <150 pg/ml • Hemogram • Bone marrow examination • Schilling’s test - measures radioactive Vit. B12 with and without intrinsic factor

  39. Treatment • Daily requirement :1 mcg • Dose : 1000 mcg / week for 1 month; 1000 mcg / month thereafter • Also add folic acid 1- 5 mg • Course: • Cutaneous changes improve within 1 year • In pernicious anemia Vitamin B12 given life long

  40. Folic acid (Vit. B9)(Pteroyl - glutamic acid, folacin) Sources: • Liver, meat, green leafy vegetables, milk • Produced by colonic bacteria (inadequate) Folic acid and Vit. B12 are interdependent, therefore the deficiencies occur simultaneously • Folic Acid Folinic acid (active form) Vit C

  41. Clinical features • Skin: Diffuse hyperpigmentation • Mucous membrane: Glossitis, superficial erosions, cheilitis • Others: Megaloblastic anemia

  42. Diagnosis and treatment Diagnosis Serum folate < 3 ng/ml (normal > 6 ng/ml) Treatment • Daily requirement : 50 -100 mcg • In pregnancy : 400 mcg Therapeutic dose: 1- 5 mg / day; also correct Vit. B12 deficiency

  43. Vitamin C (Ascorbic acid) • Scurvy: Deficiency of Vitamin C Sources: • Fresh fruits - oranges, grapes, lemons • Fresh vegetables - Green leafy vegetables, potatoes, cabbage Functions: • Role in collagen and ground substance formation, wound healing, immune response • Required for iron absorption

  44. Causes • Diet poor in Vitamin C (elderly men, alcoholics) • Gastro-intestinal diseases • Malnourished children with scurvy (Barlow's disease) • Seen in cigarette smokers

  45. Clinical features Skin • Follicular hyperkeratosis : Earliest change, cork screw hair (swan neck deformity) - due to reduced disulfide bond • Perifollicular hemorrhage Sites: upper arms, buttocks, shins, trunk, thighs • Petechiae, echhymosis • “Woody” edema of legs • Delayed wound healing

  46. Clinical features Oral Cavity: • Hemorrhagic gingivitis - spongy gum • Loosened teeth, foul odour Internal hemorrhage : • Hematuria, epistaxis, malena, hematemesis In infants: • Excessive crying • Pseudo paralysis • Scorbutic rosary

  47. Treatment • Daily requirement Adult: 50 mg Children: 25 mg • Therapeutic dose: 100 - 300 mg / day

  48. Minerals and Trace elements Zinc : • It is metal moiety of important enzymes for carbohydrate, protein, lipid and nucleic acid metabolism • Role in immunological functions and wound healing Sources: • Shellfish, legumes, nuts, whole grains, green leafy vegetables

  49. Zinc deficiency Genetic • Acrodermatitisenteropathica Acquired • Acquired zinc deficiency

  50. Acrodermatitisenteropathica • Transmitted as autosomal recessive trait • First described by Danbolt and Class in 1943 • Etiology: • Deficient zinc binding protein called zinc ligand binding (ZLB)

More Related