Nutritional Dermatoses in Children

PEM, Vit A & C - Malnutrition Markers

• Protein-Energy Malnutrition (PEM):

  • Kwashiorkor: Protein deficiency. Pitting edema, moon facies, apathy.
    • Skin: Flaky paint dermatosis, desquamation.
    • Hair: Flag sign, sparse, easily pluckable.

    ⭐ Flag sign (alternating bands of light/dark hair) is characteristic of Kwashiorkor.

  • Marasmus: Energy & protein deficiency. Severe wasting, "old man" facies. Alert, irritable. No edema. Skin: Dry, loose ("baggy pants").
  • MUAC < 11.5 cm (SAM marker).

• Vitamin A Deficiency:

  • Ocular: Night blindness, Bitot’s spots, conjunctival/corneal xerosis, keratomalacia.
  • Skin: Phrynoderma (toad skin) - follicular hyperkeratosis (elbows, knees). Dry, rough.

• Vitamin C Deficiency (Scurvy):

  • Skin: Perifollicular hemorrhages, petechiae, ecchymoses. 📌 Mnemonic: 4 H's (Hemorrhage, Hyperkeratosis...).
  • Gums: Swollen, bleeding (scorbutic gingivitis).
  • Hair: Corkscrew hairs.
  • Impaired wound healing.

B-Vitamin Deficiencies - Skin Signals

• Riboflavin (B2) - Ariboflavinosis:
  • Angular cheilitis, glossitis (magenta)
  • Seborrheic dermatitis-like rash (nasolabial, genital)
  • Oculo-oro-genital syndrome
• Niacin (B3) - Pellagra: (📌 3 D's: Dermatitis, Diarrhea, Dementia)
  • Photosensitive dermatitis (Casal's necklace, "glove & stocking")
  • Hyperpigmentation, skin thickening

  ⭐ Casal's necklace (a broad, pigmented, and often photosensitive rash around the neck) is a hallmark of Pellagra (Niacin/B3 deficiency).

• Pyridoxine (B6):
  • Seborrheic dermatitis-like rash
  • Cheilosis, glossitis
  • Drug-induced (e.g., Isoniazid)
• Biotin (B7):
  • Periorificial dermatitis (mouth, eyes, nose, anogenital)
  • Alopecia
  • Raw egg white ingestion (avidin)
• Folate (B9) / Cobalamin (B12):
  • Mucocutaneous hyperpigmentation (knuckles, creases)
  • Glossitis, angular stomatitis
  • Hair changes (B12)

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Mineral Deficiencies - Metal Maladies

• Zinc Deficiency (Acrodermatitis Enteropathica)
  • Cause: Inherited (SLC39A4) / acquired.
  • Triad: Periorificial/acral dermatitis, alopecia, diarrhea.
  • Others: Growth retardation, Beau's lines (nails).
  • Rx: Zinc sulfate 1-3 mg/kg/day elemental zinc.

  ⭐ Acrodermatitis enteropathica, caused by zinc deficiency, classically presents with periorificial and acral erythematous, vesiculobullous, or pustular dermatitis, alopecia, and diarrhea.

• Iron Deficiency
  • Skin: Pallor, koilonychia (spoon nails), angular cheilitis, glossitis.
  • Hair: Diffuse alopecia.
• Copper Deficiency (Menkes Kinky Hair Syndrome)
  • X-linked (ATP7A); impaired Cu absorption.
  • Hair: Pili torti ("kinky"), sparse, hypopigmented, brittle.
  • Skin: Hypopigmentation, lax skin.
  • Systemic: Neurodegeneration, FTT.
  • 📌 MENKES: Mental retardation, Epilepsy, Neural degen, Kinky hair, Elastic tissue degen, Subnormal temp.
• Selenium Deficiency
  • Skin/Hair: Hypopigmentation (pseudoalbinism), nail whitening.
  • Systemic: Cardiomyopathy (Keshan disease), myopathy.

EFAD, Dx & Mgmt - Fix & Finish

• Essential Fatty Acid Deficiency (EFAD):

  • Cause: ↓ Linoleic (LA, ω-6) & α-linolenic (ALA, ω-3) acids.
  • Clinical: Xerosis ("crazy paving" skin), eczematous dermatitis, alopecia, FTT, thrombocytopenia, impaired wound healing. 📌 "SCALP" (Scaly skin, Cutaneous lesions, Alopecia, Low platelets, Poor growth).
  • Dx: Clinical. Lab: Triene:tetraene ratio > 0.2 (Normal < 0.02).
  • Rx: Dietary oils (sunflower, safflower, fish), topical emollients.

• Nutritional Dermatoses: General Approach

  • Diagnosis: Detailed dietary history, clinical exam (skin, hair, nails, mucosae), targeted labs (nutrient levels).
  • Management:

⭐ Essential fatty acid deficiency can manifest as dry, scaly skin (xerosis), eczematous lesions, and poor wound healing.

High-Yield Points - ⚡ Biggest Takeaways

• Kwashiorkor: Key: flaky paint dermatosis, enamel paint nails, hair flag sign.
• Marasmus: Features: "monkey facies", "baggy pants" skin folds, severe muscle wasting.
• Phrynoderma (Vit A def.): Follicular hyperkeratosis ("toad skin") on elbows, knees, buttocks.
• Acrodermatitis Enteropathica (Zinc def.): Triad: periorificial/acral dermatitis, alopecia, diarrhea.
• Scurvy (Vit C def.): Signs: corkscrew hairs, perifollicular hemorrhages, swollen/bleeding gums.
• Pellagra (Niacin/B3 def.): Casal's necklace (photosensitive rash), "3 Ds" (dermatitis, diarrhea, dementia).