GRAND CAYMAN, CAYMAN ISLANDS — Consider the possibility of acquired zinc deficiency in patients with persistent red, scaly skin on the hands and feet, Dr. Christopher O'Connell proposed at the Caribbean Dermatology Symposium.
Dr. O'Connell, a dermatology resident at St. Luke's-Roosevelt Hospital Center in New York, described the case of a 49-year-old black woman who presented with severe erythema, edema, and scaling on her palms and soles, as well as scaly patches and fissures on the backs of her hands. In addition, she had edema and erythema on her lower legs, as well as nonblanchable brown and red patches on her upper thighs. At follow-up exams, some of the nonblanchable patches had become scaly, and some of the scaly patches had progressed to form bullae and erosions.
The patient's medical history included type 2 diabetes, end-stage renal disease, hypertension, and alcohol abuse. She had completed a 2-week course of vancomycin and gentamycin for Staphylococcus aureus bacteremia one week prior to her evaluation in the dermatology department.
“This patient's alcohol abuse and renal disease were the likely causes of her acquired zinc deficiency and consequent acrodermatitis,” Dr. O'Connell said.
The initial laboratory tests revealed chronic anemia. All other blood work was normal, and blood cultures were negative. The initial differential diagnosis included staphylococcal scalded skin syndrome, a drug reaction, and vasculitis.
“A skin biopsy was performed and the histopathology was consistent with nutritional deficiency,” he said. Histologic findings that supported the final diagnosis included compact parakeratosis, pallor of the upper epidermis, hypogranulosis, intraepidermal vesiculation, keratinocyte necrosis, and architectural disarray.
Based in part on the histology findings, the differential diagnosis was expanded to include necrolytic migratory erythema, pellagra, and zinc deficiency.
Necrolytic migratory erythema was unlikely because the patient's glucose levels were well controlled on low-dose insulin glargine and a CT scan of the abdomen showed no signs of pancreatic neoplasm. Pellagra was ruled out because the rash was not photodistributed.
On further testing, the patient's zinc level was 615 mcg/L, compared with the normal, healthy range of 670–1,240 mcg/L. The diagnosis of zinc deficiency was confirmed when the patient's skin improved after zinc supplementation. The patient died, however, of complications from her renal disease.
“The skin contains 6% of the body's supply of zinc and it is the most common organ to demonstrate clinical signs of zinc deficiency,” Dr. O'Connell noted.
Acquired zinc deficiency has been reported in association with many medical disorders, including alcoholism, renal disease, gastrointestinal malabsorption syndromes, food allergies, anorexia, and severe burns. Research has shown that more than 300 enzymes require zinc in order to function. Zinc is essential for protein, carbohydrate, and fat metabolism, as well as for healthy immune system function, cell growth, and wound healing.
Hereditary zinc deficiency presents with a clinical picture similar to acquired zinc deficiency; however, it is an autosomal recessive disorder that usually presents within the first 4–10 weeks of life, he said.
The presentation of acquired zinc deficiency included non-blanchable brown and red patches on the upper thighs. Courtesy Dr. Christopher O'Connell