Protein-Energy Malnutrition (PEM)
Skin and hair changes are hallmark features of severe malnutrition, particularly edematous malnutrition (Kwashiorkor).
Kwashiorkor (Edematous Malnutrition)
- General Appearance: The child often presents with edema, which may mask muscle wasting, giving a “sugar baby” appearance.
- “Flaky Paint” Dermatosis: This is pathognomonic for kwashiorkor. The skin becomes hyperpigmented, turning jet black or erythematous. These pigmented patches eventually peel off (desquamate) to expose raw, hypopigmented areas underneath, resembling peeling paint,.
- “Crazy Pavement” Dermatosis: Extensive cracked lesions appear, particularly in the flexures, groin, and buttocks. These areas are prone to infection and ulceration.
- Ulceration and Exudation: The skin may show deep ulcerations spreading over limbs, thighs, genitalia, and behind the ears. Exudative lesions may resemble severe burns and are frequently secondarily infected with bacteria or Candida,.
- Dyspigmentation: The skin may show diffuse depigmentation or patchy hyperpigmentation,.
- Hair Changes:
- Hypochromotrichia: Hair becomes hypopigmented or reddish/brown.
- Texture: Hair becomes sparse, thin, brittle, and lacks luster,.
- Pluckability: Hair is easily pluckable without pain,.
- Flag Sign: Alternating bands of light (hypopigmented) and normal color hair strands indicate periods of poor and good nutrition during hair growth,,.
- Straightening: Curly hair may become straight,.
Marasmus (Non-Edematous Malnutrition)
- Loss of Subcutaneous Fat: There is extreme wasting of subcutaneous fat and muscle.
- Wrinkling: The skin is loose, hanging in folds, and wrinkled due to the loss of underlying tissue,.
- “Baggy Pants” Appearance: Loose folds of skin are particularly prominent on the buttocks and thighs, creating the appearance of wearing baggy pants,,.
- Simian Facies: Loss of the buccal pad of fat gives the child an old man or wizened appearance (monkey facies),.
- Turgor: Skin turgor is reduced; the skin flattens very slowly when pinched, which can mimic dehydration.
Fat-Soluble Vitamin Deficiencies
Vitamin A Deficiency
- Follicular Hyperkeratosis (Phrynoderma): This condition, also known as “toad skin,” presents as rough skin with raised hyperkeratotic patches,. It typically involves the shoulders, arms, legs, and buttocks.
- Xerosis: The skin becomes generally dry and scaly due to the loss of epithelial integrity and sweat/sebaceous gland atrophy,,.
- Mucosal Changes: Metaplasia of the epithelial lining leads to keratinization of mucous membranes.
- Carotenemia (Excess Precursor): Excessive intake of beta-carotene (e.g., from carrots) causes yellow-orange pigmentation of the skin, most visible on the palms, soles, and nasolabial folds, but notably sparing the sclera (unlike jaundice),.
Vitamin E Deficiency
- General: While primarily neurological, deficiency in premature infants is associated with edema involving the legs and labia [Note: derived from clinical context of hemolytic anemia in preterms].
- Seborrheic Dermatitis: Can be associated with deficiency.
Vitamin K Deficiency
- Hemorrhagic Manifestations: Deficiency presents with cutaneous bleeding such as petechiae, ecchymoses (bruising), and bleeding from puncture sites or the umbilical stump.
Water-Soluble Vitamin Deficiencies
Riboflavin (Vitamin B2)
- Angular Stomatitis: Inflammation and fissures at the corners of the mouth (angles of the lips),.
- Cheilosis: Pallor, thinning, and maceration of the epithelium of the lips, leading to vertical fissuring,.
- Glossitis: The tongue becomes smooth and magenta-colored (atrophic papillae),.
- Seborrheic Dermatitis: Scaly, greasy lesions typically appearing around the nasolabial folds (nasolabial dyssebacea), eyes, and ears,,.
- Scrotal/Vulval Dermatitis: Inflammation and desquamation of the genitalia,.
Niacin (Vitamin B3) - Pellagra
- Photosensitive Dermatitis: This is the hallmark of pellagra. Lesions appear symmetrically on sun-exposed areas,.
- Casal’s Necklace: A characteristic collar-like hyperpigmented rash around the neck,.
- Glove and Stocking Dermatitis: Sharply demarcated symmetric erythema and pigmentation on the hands and feet,.
- Progression: Lesions start as erythema resembling sunburn, becoming hyperpigmented and keratotic. In acute “wet” pellagra, vesicles and bullae may form, leading to desquamation and crusting.
- Mucosal Changes: Stomatitis, cheilosis, and a raw, beefy red tongue (glossitis),.
Pyridoxine (Vitamin B6)
- Seborrheic Dermatitis: Scaly rash occurring around the eyes, nose, and mouth.
- Cheilosis and Glossitis: Similar to riboflavin deficiency.
Biotin (Vitamin B7)
- Periorificial Dermatitis: Scaly, red rash around the eyes, nose, mouth, and perineum,.
- Alopecia: Thinning of hair leading to total hair loss,.
- Conjunctivitis: Often accompanies the dermatitis.
Cobalamin (Vitamin B12)
- Hyperpigmentation: Characteristic hyperpigmentation of the knuckles, nail beds, palms, and soles,.
- Hair Changes: Hair may become thin and sparse.
- Mucosal: Glossitis with a smooth, beefy red tongue.
Vitamin C (Scurvy)
- Perifollicular Hemorrhages: Bleeding around hair follicles is a specific sign.
- Follicular Hyperkeratosis: The hair follicles become enlarged and rough (corkscrew hairs may be seen),,.
- Petechiae and Ecchymoses: Spontaneous bruising and pinpoint hemorrhages, particularly at pressure points,.
- Gingival Changes: In children with erupted teeth, gums become swollen, spongy, bluish-purple, and bleed easily (scorbutic gums),.
- Wound Healing: Delayed wound healing and breakdown of old scars,.
Trace Element Deficiencies
Zinc
- Acrodermatitis Enteropathica: A severe deficiency state characterized by vesicobullous, eczematous, and crusted lesions,.
- Distribution: Lesions are typically located in periorificial areas (around the mouth, eyes, anus) and acral areas (fingers, toes, heels),.
- Alopecia: Generalized hair loss,.
- Nails: Paronychia (inflammation around the nail) and nail dystrophy.
- Mucosal: Stomatitis and glossitis.
- Wound Healing: Poor or delayed wound healing,.
Copper
- Hypopigmentation: Depigmentation of the skin and hair due to impaired melanin synthesis,,.
- Hair Changes: In Menkes kinky hair syndrome (a defect in copper transport), hair becomes sparse, lusterless, twisted (pili torti), and coarse (steely/kinky),.
Iron
- Pallor: Pale skin and mucous membranes due to anemia,.
- Koilonychia: Spoon-shaped, concave nails that are thin and brittle,.
- Plummer-Vinson Syndrome: Associated with angular stomatitis and glossitis (atrophy of lingual papillae),.
Selenium
- Hair and Nail Changes: Whitening of nail beds and hair loss/changes in hair color,.
Essential Fatty Acid Deficiency
- Dermatitis: Dry, scaly, desquamating skin rashes.
- Alopecia: Hair loss.
- Wound Healing: Impaired wound healing.
- Hemorrhagic Folliculitis: Associated with alpha-linolenic acid deficiency.