Cutaneous manifestation of micronutrient deficiency

Protein-Energy Malnutrition (PEM)

Skin and hair changes are hallmark features of severe malnutrition, particularly edematous malnutrition (Kwashiorkor).

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,.

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.

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),.

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.

Hemorrhagic Manifestations: Deficiency presents with cutaneous bleeding such as petechiae, ecchymoses (bruising), and bleeding from puncture sites or the umbilical stump.

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,.

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),.

Seborrheic Dermatitis: Scaly rash occurring around the eyes, nose, and mouth.
Cheilosis and Glossitis: Similar to riboflavin deficiency.

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.

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.

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,.

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,.

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),.

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),.

Hair and Nail Changes: Whitening of nail beds and hair loss/changes in hair color,.