DermAtlas: Online Dermatology Image Library dermatology image,pellagra,kwashiorkor,nutritional deficiency,acrodermatitis enteropathica,zinc deficiency

© 2001-2009, DermAtlas	*Image Name:*	Pellagra_1_031007	*File Type:*	jpg
	*Diagnosis:*	PELLAGRA	*Category:*	photosensitivity, photoexacerbated / nutritional deficiency / hyperpigmentation / papulosquamous eruptions
	*Body Site:*	hand / foot	*Age:*	40 years
	*Contributor:*	Jayakar Thomas, MD. PhD
	*Description:*	symmetric scaly erythematous plaques in sun exposed sites
	*Comments:*	A 40-year-old man developed scaly reddish-brown plaques on the sun exposed areas of the hands and feet. He did have a history of photosensitivity (itching and burning with sun exposure) and chronic alcohol abuse.

© 2001-2009, DermAtlas	*Image Name:*	kwashiorkor_1_050112	*File Type:*	jpg
	*Diagnosis:*	KWASHIORKOR / NUTRITIONAL DEFICIENCY	*Category:*	cutaneous sign of systemic disease / nutritional deficiency
	*Body Site:*	arm / shoulder	*Age:*	14 months
	*Contributor:*	Albert Yan, MD
	*Description:*	diffuse brown and erythematous reticulated scaly plaques with a flaky paint appearance
	*Comments:*	This 14-month-old girl was brought to the emergency room by her parents after a 3-week history of total body swelling and a 2-week history of a rash that began in the diaper area and then spread diffusely. Her hair had become lighter at the roots, and her skin color had become more pallid. She had been breast-fed until age 8 months. Attempts to change her to formula feeds were unsuccessful, since she did not like them. She was started on a diet of a rice-based beverage (Rice Dream, Imagine Foods, Garden City, NY), vegetables, and some meat. Solid-food consumption decreased in the weeks before presentation, as the patient began teething. Kwashiorkor is a disease caused by protein-energy malnutrition. The condition is characterized by a “flaky paint” appearance of the skin, pigment loss, anasarca, and apathy. The term “kwashiorkor,” first used in the English literature in a report by C.D. Williams in The Lancet in 1935, derives from the local word for the disease in Ghana, where it was associated with a maize diet. Still endemic in Africa and in developing countries, kwashiorkor in developed countries has usually been associated with cystic fibrosis or other chronic malabsorptive conditions. Recently, however, new causes of kwashiorkor in the United States have been reported. Fad diets, perceived and true milk allergy, and nutritional ignorance have been implicated in 14 children diagnosed with kwashiorkor in the United States in the past decade. Rice-based beverages – often popularly referred to as “rice milk,” and containing less than half the amount of protein of breast milk – were a significant part of the feeding regimen in two of these children. Other feeding regimens in these children included brown rice emulsion, goat’s milk, and atole (a liquid emulsion of barley, water, and sugar popular in Mexico). Only two of the cases were associated with poverty. Half of the cases were associated with a perceived or presumed food allergy. Like the patient presented here, six of these children have had zinc deficiency as well as kwashiorkor. The presence of anasarca and hypoalbuminemia suggested, however, that kwashiorkor was the primary problem. Four patients received zinc supplementation, while the other two were re-fed without zinc supplementation. All six patients recovered. Zinc levels in suspected kwashiorkor patients, however, should be checked; low levels of alkaline phosphatase, a zinc-dependent enzyme, often indicate zinc deficiency. Other entities in the differential diagnosis of kwashiorkor include free fatty acid or multiple carboxylase deficiency, immunodeficiency syndromes, malabsorption syndromes, cystic fibrosis, and Langerhans cell histiocytosis. References: 1. Buno IJ, Morelli JG, Weston WL. The Enamel Paint Sign in the Dermatologic Diagnosis of Early-Onset Kwashiorkor. Arch Dermatol. 1998;134:107-8. 2. Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe Nutritional Deficiencies in Toddlers Resulting From Health Food Milk Alternatives. Pediatrics. 2001;107:e46. 3. Liu T, Frieden IJ. Rice Dream Nondairy Beverages. Arch Dermatol. 2002;138:838. 4. Liu T, Howard RM, Mancini AJ, et al. Kwashiorkor in the United States: Fad Diets, Perceived and True Milk Allergy, and Nutritional Ignorance. Arch Dermatol. 2001;137:630-6.

© 2001-2009, DermAtlas	*Image Name:*	Acrodermatitis_enteropathica_1_050103	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / ZINC DEFICIENCY	*Category:*	nutritional deficiency / cutaneous sign of systemic disease / vesiculobullous eruptions / papulosquamous eruptions
	*Body Site:*	trunk / face eye lid / face neck / arm	*Age:*	5 months
	*Contributor:*	Nahide Onsun, MD
	*Description:*	symmetric, periorificial and intertriginous, erythematous, eroded, crusted patches
	*Comments:*	This healthy 5-monthold girl developed an erosive intertriginous and periorificial dermatitis 1 month after weaning from breast milk. She was fussy and her weight began to fall after rapid growth during the first 4 months of life. Her symptoms and the eruption cleared quickly after she was administered daily supplemental zinc.
	*Related Images:*	All related Images Acrodermatitis_enteropathica_2_050103 Acrodermatitis_enteropathica_3_050103

© 2001-2009, DermAtlas	*Image Name:*	Acrodermatitis_enteropathica_3_050103	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / ZINC DEFICIENCY	*Category:*	nutritional deficiency / papulosquamous eruptions / vesiculobullous eruptions / cutaneous sign of systemic disease
	*Body Site:*	genital / sole diaper area / foot	*Age:*	5 months
	*Contributor:*	Nahide Onsun, MD
	*Description:*	symmetric, periorificial and intertriginous, erythematous, eroded, crusted patches
	*Comments:*	This healthy 5-monthold girl developed an erosive intertriginous and periorificial dermatitis 1 month after weaning from breast milk. She was fussy and her weight began to fall after rapid growth during the first 4 months of life. Her symptoms and the eruption cleared quickly after she was administered daily supplemental zinc.
	*Related Images:*	All related Images Acrodermatitis_enteropathica_2_050103 Acrodermatitis_enteropathica_1_050103

© 2001-2009, DermAtlas	*Image Name:*	Acrodermatitis_enteropathica_2_050103	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / ZINC DEFICIENCY	*Category:*	nutritional deficiency / papulosquamous eruptions / vesiculobullous eruptions / cutaneous sign of systemic disease
	*Body Site:*	trunk / face neck / groin diaper area / suprapubic area	*Age:*	5 months
	*Contributor:*	Nahide Onsun, MD
	*Description:*	symmetric, periorificial and intertriginous, erythematous, eroded, crusted patches
	*Comments:*	This healthy 5-monthold girl developed an erosive intertriginous and periorificial dermatitis 1 month after weaning from breast milk. She was fussy and her weight began to fall after rapid growth during the first 4 months of life. Her symptoms and the eruption cleared quickly after she was administered daily supplemental zinc.
	*Related Images:*	All related Images Acrodermatitis_enteropathica_3_050103 Acrodermatitis_enteropathica_1_050103

© 2001-2009, DermAtlas	*Image Name:*	acquired_zinc_deficiency_1_030602	*File Type:*	jpg
	*Diagnosis:*	ZINC DEFICIENCY / NUTRITIONAL DEFICIENCY	*Category:*	nutritional deficiency / cutaneous sign of systemic disease
	*Body Site:*	knee / elbow foot / finger hand	*Age:*	9 years
	*Contributor:*	Jayanta Das, MD, DVD
	*Description:*	symmetric hyperpigmented thin adherent crusted scale
	*Comments:*	This 9-year-old girl, who was profoundly malnourished, developed hyperpigmented thin adherent scales over bony prominences, in skin creases, and in periorificial areas. The lesions healed quickly with refeeding and zinc supplementation.

© 2001-2009, DermAtlas	*Image Name:*	acrodermatitis_enteropathica_2_030415	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / ZINC DEFICIENCY	*Category:*	nutritional deficiency / Metabolic disorders / cutaneous sign of systemic disease / vesiculobullous eruptions
	*Body Site:*	eye lid / forehead lip	*Age:*	6 months
	*Contributor:*	Debabrata Bandyopadhyay, MD
	*Description:*	symmetric periorificial eroded, crusted, scaly plaques
	*Comments:*	This 6-month-old boy developed symmetric, crusted, scaly, and erosive periorificial plaques associated with diarrhea and alopecia. Lesions were also present on the elbows, scalp, and intertriginous regions. Oral zinc therapy led to dramatic resolution of symptoms and disappearance of the rash.
	*Related Images:*	acrodermatitis_enteropathica_1_030415

© 2001-2009, DermAtlas	*Image Name:*	acrodermatitis_enteropathica_1_030415	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / ZINC DEFICIENCY	*Category:*	nutritional deficiency / Metabolic disorders / cutaneous sign of systemic disease / vesiculobullous eruptions
	*Body Site:*	buttock / scalp elbow / diaper area	*Age:*	6 months
	*Contributor:*	Debabrata Bandyopadhyay, MD
	*Description:*	symmetric periorificial eroded, crusted, scaly plaques
	*Comments:*	This 6-month-old boy developed symmetric, crusted, scaly, and erosive periorificial plaques associated with diarrhea and alopecia. Lesions were also present on the elbows, scalp, and intertriginous regions. Oral zinc therapy led to dramatic resolution of symptoms and disappearance of the rash.
	*Related Images:*	acrodermatitis_enteropathica_2_030415

© 2001-2009, DermAtlas	*Image Name:*	aep_1_010727	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / NUTRITIONAL DEFICIENCY / ZINC DEFICIENCY	*Category:*	nutritional deficiency / papulosquamous eruptions / Metabolic disorders
	*Body Site:*	total body	*Age:*	6 months
	*Contributor:*	Bernard Cohen, MD
	*Description:*	resolving erosive papulosquamous eruption
	*Comments:*	At 6 months of age a healthy infant developed a diffuse progressive erosive crusted rash with accentuation of lesions in skin creases and at mucocutaneous junctions. He was exclusively breast-fed until one month earlier when his mother returned to work and weaned him to cow's milk based formula. Growth was normal until 6 months of age when he stopped gaining weight, developed diarrhea, and became fussy and listless. Laboratory studies were normal except for low zinc levels. His symptoms and rash resolved within 3 days of initiating oral zinc gluconate supplements.
	*Related Images:*	All related Images aep_3_010727 aep_2_010727

© 2001-2009, DermAtlas	*Image Name:*	aep_2_010727	*File Type:*	jpg
	*Diagnosis:*	ACRODERMATITIS ENTEROPATHICA / NUTRITIONAL DEFICIENCY / ZINC DEFICIENCY	*Category:*	nutritional deficiency / papulosquamous eruptions / Metabolic disorders
	*Body Site:*	diaper area / buttock thigh / genital	*Age:*	6 months
	*Contributor:*	Bernard Cohen, MD
	*Description:*	diffuse symmetric red scaly patches with erosions and crusts
	*Comments:*	At 6 months of age a healthy infant developed a diffuse progressive erosive crusted rash with accentuation of lesions in skin creases and at mucocutaneous junctions. He was exclusively breast-fed until one month earlier when his mother returned to work and weaned him to cow's milk based formula. Growth was normal until 6 months of age when he stopped gaining weight, developed diarrhea, and became fussy and listless. Laboratory studies were normal except for low zinc levels. His symptoms and rash resolved within 3 days of initiating oral zinc gluconate supplements.
	*Related Images:*	All related Images aep_3_010727 aep_1_010727

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© DermAtlas, Johns Hopkins University; 2000-2009
Bernard A. Cohen, MD, Christoph U. Lehmann, MD
DermAtlas was last updated: Oct-28-2009
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