Zinc Deficiency

A 44-year-old woman had a painful, burning rash for 4 months. The erythematous eruption was evident on the thighs, fingers, buttocks, abdomen, and perineal and intergluteal areas. Application of triamcinolone cream and emollients offered no relief.

The patient lived in a nursing home. She had a history of chronic alcoholism with subsequent liver failure but denied using alcohol for the last 3 months. She complained of poor appetite and progressive weight loss. Her medications included vitamin supplements.

The patient was cachectic and extremely weak; eye contact was poor. She showed no signs of jaundice. The extensive eruption exhibited focal annularity and no vesiculation. Fine scale was most dense along the leading edges of the lesions; a negative potassium hydroxide examination ruled out a dermatophyte infection.

Laboratory studies revealed no evidence of anemia; however, the serum zinc level was 28 µg/dL (normal, 80 to 120 µg/dL). Joe Monroe, PA-C, of Tulsa, Okla, found that the patient's vitamin supplements did not contain zinc.

A punch biopsy specimen showed psoriasiform changes, parakeratosis, and a sparse superficial perivascular lymphohistiocytic infiltrate-skin changes that are secondary to zinc deficiency. The lack of eosinophils in the infiltrate ruled out contact dermatitis; the absence of stigmata and a family history of psoriasis excluded that disease. Zinc deficiency, or acrodermatitis enteropathica, was diagnosed.

Acrodermatitis enteropathica formerly referred to an inherited disorder that predominantly affected infants. Recently, the definition has been broadened to include any dermal syndrome that involves zinc deficiency with acral eruption.¹

Alcoholism and cirrhosis cause hypozincemia by increasing urinary loss of the metal, which may already be at low levels because of insufficient dietary intake. Other causes of nonhereditary acrodermatitis enteropathica include GI diseases and catabolic processes. A daily oral dose of zinc sulfate, 200 mg, was prescribed for this patient.

One week after these pictures were taken, the patient died of cardiac arrest. The association of zinc deficiency to her death is unclear.

REFERENCE:1. Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York: McGraw-Hill; 1999:1738-1744.