Zinc Deficiency Syndrome?

Abstract:  53 yo woman with one month history of wide-spread dermatitis.

HPI:  The patient is a massively obese woman who weighed 750 pounds a year before her office visit but at present weighs around 350 pounds.  Her weight loss has been achieved by severe calorie restriction (she lives in a care facility).  Her skin was clear until a month before the office visit.  By history, the dermatitis began on hands and arms, spread to skin folds, postauricular areas and angles of mouth.  She has had some diarrhea.

O/E:  The patient appeared alert, tired and massively obese. She had a papulosquamous eruption on arms consisting of erythematous patches with fine superficial scale.  There was erythema in all examined skin folds with mild serous discharge.  She had an erosive postauricular dermatitis and angular cheilitis (see photo).  Dental hygiene was good and KOH prep from angle of mouth showed very rare yeast forms.

Clinical Photo:

Lab:  Post auricular culture grew Staph aureus (MRSA) and Pseumonas.  Serum zinc 0.58 mcg/ml (normal 0.66 - 1.1 mcg/ml)

Biopsy from arm lesion showed orthokeratosis, subcorneal neutrophils, focal hypogranulosis and psoriasiform hyperplasia consitent with psoriasis or given her history acrodermatitis enteropathica.

Diagnosis:  The short history of dermatitis here suggests a nutritional etiology may be considered.  This woman had no history of skin disease until a month before her office visit.  She had been on a very restrictive diet and it is unclear how carefully vitamins and micronutrients had been monitored.  The low zinc level may not be the only deficiency she has.  Her MRSA should be addressed, but low zinc may have set up a situation where MRSA could thrive in skin folds (an altered skin microbiome).

Questions and Comments:  This is a complex case and it is unlikely that sinc supplements will address all of this woman's needs.  A nutritionist may help.  The angular cheilitis was a clue to "think zinc."  Her MRSA needs to be addressed as well as the intertrigo.  She is relatively young and healthy. Considering her obesity, a multidisciplinary approach could help her.  In the setting of a group home this may not be forthcoming.  Patients like this can be marginalized in any health-care setting and present diagnostic and management problems.  There are many more questions?  What did her hemogram show?

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Nail Dystrophy in an Eight Year-Old Girl

Introduction:  In the past, we published a case of localized acrodermatitis continua.  The father of a child with this diagnosis in the U.S. came across our post on VGRD and asked our advice for his daughter.  Your opinions may help with the diagnosis and management of this child.  One can only imagine how this disorder impacts on a young child. Perhaps, one of us has had a favorable outcome with a similar patient.


History:  Please help with an opinion on our eight year-old daughter who has had an acral dermatitis for the past 5 years.   The swelling started at the cuticle and slowly moved back towards the first knuckle over the years and was associated with itching. Initially it was diagnosed as insect bites.  About a year ago her fingers became more swollen and a doctor made a clinical diagnosis of fungus (no tests were done).  She was treated first with vinegar soaks, then triamcinalone cream then Grifulvin 125mg/tsp.  None was effective and we then saw a new dermatologist who referred us to a pediatric dermatologist who she made a diagnosis: Acrodermatitis Continua of Hallopeau.  She did a fungal culture which grew out a soil contaminant that was not felt to be significant.   Our daughter is presently on clobetasol ointment.  The nail looks a bit better but not the skin.  Treatment discussions so far have included Thalidomide, Psoralen plus UVA or UVB, Acitretin, Methotrexate and others.  We know that these medications can have serious side-effects and that this disease can be resistant to treatment.  Our daughter has a lot of finger pain and can't pick up thing with her fingers.  She is only a child and we'd appreciate your thoughts.

Clinical Photos:

Questions:
1) Are there alternative diagnoses?
2) What therapies have you had success within similar cases?
3)  Any further work-up?

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Interesting Follow-up: Paronychia in a Child

In October 2007, we presented the case of an eight year old girl with chronic paronychial inflammation located on the left index finger (Paronychia in a Child). She had no other dermatoses. The patient is adopted so we have no family history. We assumed this was some kind of localized psoriasis or acrodermatitis continua. Clobetasol ointment was prescribed which she has used since. (Photo above from 10/2007)

The patient was seen in follow-up recently. The paronycial inflammation had subsided but the finger tip was still abnormal, especially on the palmar surface and there is now hypopigmentation and atrophy distal to the area of inflammation. This latter is likely secondary to the clobetasol. Her topical therapy was switched to calcipotriene cream (the ointment is no longer available in the US.)

Photos:






Questions:
1) What do you think the diagnosis is?
2) Side-effects on the fingers from super-potent topical corticosteroids are rarely reported. One suspects that they are not that unusual. When does the treatment get worse than the disease? (I should have been more diligent in follow-up)
3) Who thinks that these preparations can cause bone changes?
Your comments will be appreciated.

References:
1. Deffer TA, Goette DK.. Distal phalangeal atrophy secondary to topical steroid therapy. Arch Dermatol. 1987 May;123(5):571-2.

2. Tosti A, Fanti PA, Morelli R, Bardazzi F. Psoriasiform acral dermatitis. Report of three cases. Acta Derm Venereol. 1992;72(3):206-7.
Department of Dermatology, University of Bologna, Italy.
The authors report 3 patients affected by psoriasiform acral dermatitis, a distinctive clinical entity characterized by a chronic dermatitis of the terminal phalanges, associated with marked shortening of the nail beds of the affected fingers. The skin biopsy showed in all cases the pathological features of a subacute spongiotic dermatitis. X-ray examination of affected fingers showed no bone or soft tissue changes. Differential diagnosis of psoriasiform acral dermatitis included psoriasis, atopic or contact dermatitis and corticosteroid-induced distal phalangeal atrophy.

3. Brill TJ, Elshorst-Schmidt T, Valesky EM, Kaufmann R, Thaçi D. Successful treatment of acrodermatitis continua of Hallopeau with sequential combination of calcipotriol and tacrolimus ointments. Dermatology. 2005;211(4):351-5.
Department of Dermatology, J.W. Goethe University, Frankfurt, Germany.
Acrodermatitis continua of Hallopeau (ACH) is a rare type of pustular psoriasis affecting the digits. We report on a 43-year-old female patient who had been suffering from ACH for more than 20 years. Despite the fact that the disease was localized on one finger during the whole period, several topical and systemic treatments resulted in only temporary or partial improvement of the lesion. Although the monotherapies with calcipotriol and tacrolimus ointments gave no satisfying results in the long-term management of the disease, the combination of both agents led to a continuous improvement of the patient's skin condition. Copyright 2005 S. Karger AG, Basel.

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