Skin Changes That Result From Malabsorption
Malabsorption shows on your skin
Do you suffer from Malabsorption?
Malabsorption is a condition characterized by a decreased intestinal uptake of nutrients and associated with an increased excretion of fat in stools(steatorrhoea). This may lead to various degrees of lack of proteins, minerals, trace elements, fat soluble vitamins, carbohydrates, and water.
Manifestations of Malabsorption:
- Steatorrhoea (bulky, light-colored stools).
- Weight loss; Malnutrition (muscle wasting), weakness, fatigue and abdominal distension
- Iron deficiency anemia
- Paraesthesias (altered sensations and tingling) and Tetany
- Bone pains, Pathological fractures
- Bleeding tendencies (easy bruising, blood in stools, blood in urine)
- Edema (swelling of the body)
- Nocturia (increased urination at night)
- Milk intolerance (cramps, bloating, diarrhea)
Causes of Malabsorption
The major reasons that lead to malabsorption include the following:
- Chelating substances like phytates in the gut
- Insufficient digestive enzyme activity due to pancreatic diseases, obstructive jaundice, liver cirrhosis
- Contaminated small bowel syndrome due to presence of abnormal bacteria in the small intestine
- Gastric resection (Bariatric surgery ) leading to lack of hydrochloric acid production
- Stagnant loop syndrome due to strictures of the intestine
- Coeliac disease
- Zinc deficiency
- Lack of absorption capacity of intestines due to intestinal resection, Crohn's disease, pernicious anemia
- Interference with intestinal lymphatic supply due to Tubercular infection of lymph nodes or Hodgkin's lymphoma
- Diabetes mellitus
Non specific skin symptoms of malabsorption
Nonspecific symptoms may be observed in people who have lost weight due to malabsorption or malignancy. The skin changes reflect general illness rather than a specific disease. These include the following:
1. Itching and Acquired ichthyosis
Ill health is often associated with pallid, rough, dry, scaly skin, that is usually itchy. Elderly people are especially prone to dry skin, which easily becomes eczematized. Hypoferraemia may cause itch, which disappears after initiation of iron therapy.
Malnutrition associated with malabsorption causes hair to grow more slowly, fall out more easily and become grey. The hair root diameter and proportion of hair in the growing or anagen phase decrease. Protein deficiency causes the hair to lose their pigment and become red-yellow to white and curly. There may be alternating bands of pale and dark hair. Total parenteral nutrition (no food by mouth) is associated with hair loss and pigmentation of the remaining hair.
In conditions associated with malabsorption, nails grow more slowly, become brittle and may develop fissures. Multiple pigmented bands may develop on the nails. Spoon-shaped nails in malnourished persons indicate iron deficiency, even without anemia. White nails thought to be due to selenium deficiency, occur with total parenteral nutrition.
4. Skin colour
Malabsorption leads to increased pigmentation of the skin, that is most pronounced on the face. Vitamin-B12 deficiency causes pigmentation of forearms and legs in a "glove and stocking" pattern. Protein deficiency leads to a generalized lightening of the skin. The skin may turn pale due to anemia, wasting and skin atrophy associated with malnutrition.
5. Skin texture and elasticity
In the course of wasting diseases, the skin becomes thinner, dry and less elastic. Added to this, constriction of blood vessels leads to a cold, cyanotic blueing of skin.
People with gross obesity occasionally undergo treatment by gastric bypass or reduction. Dryness of skin, hair loss and inflammatory skin lesions have occurred as a result of this, along with recurrent fever and joint pains, as a result of associated malabsorption.
Malabsorption- a general overview
- Malabsorption is associated with decreased intestinal uptake, that is a lack of absorption of nutrients from the food.
- It presents as bulky, foul-smelling stools, abdominal distension, weight loss, weakness and muscle wasting.
- It results in dry, rough, itchy skin, which is thinned out and loses elasticity, along with fragile, brittle nails, and hair that turn grey and readily fall off.
- When deficiencies of specific nutrients occur, they show up as pellagra due to Vitamin-B3 deficiency, pigmentation of forearms and legs on a "glove and stocking" pattern in Vitamin-B12 deficiency, and "corkscrew" hair with easy bruising in scurvy.
- To treat malabsorption, treatment of specific causative conditions is necessary along with management of individual symptoms.
Skin signs of malabsorption of specific nutrients
Deficiencies of various nutrients can reflect on the skin. For example, vitamin deficiency can follow intestinal surgery, pancreatic disease, malabsorption syndromes and malnutrition, including those associated with alcoholism. The effects of such deficiencies vary:
- Vitamin-A deficiency causes xerotic (extremely dry), wrinkled skin covered with fine scales, occasionally accompanied by deep erosions and fissures in the skin (dermatomalacia).
- Deficiency of Vitamin-B3 causes pellagra, with its triad of diarrhea, dermatitis, dementia. The skin changes may overlap with essential fatty acid deficiencies.
- Vitamin-B12 (cyanocobalamin) deficiency is common in ileal (small intestinal) malabsorption syndromes, such as pancreatic diseases. In this, there is a symmetrical "glove and stocking" hyperpigmentation of forearms and legs, but a lemon yellow pallor of the skin elsewhere.
- Vitamin-C deficiency leads to scurvy, with "corkscrew hair", haemorrhages and small bumps on the skin, called follicular keratoses.
- Malabsorption of Vitamin-K occurs in obstructive jaundice, and leads to defects in blood coagulation, resulting in skin haemorrhage, with bruising or ecchymosis and purpura.
- Iron deficiency presents with angular stomatitis (swelling and redness at the angles of the mouth), smooth painful tongue and fragile or brittle nails, which have longitudinal ridges and lamellation. In marked iron deficiency anemia, koilonychia, a spoon like convexity of nails, develops. Hair changes include diffuse scalp hair loss with brittle, split hairs. All the signs take a long time to resolve on replacement therapy. Iron deficiency is also associated with itching.
- Zinc deficiency results from acrodermatitis enteropathica, malabsorption, or a lack of zinc when an individual is on long-term parenteral nutrition, that is on intravenous fluids. Acrodermatitis enteropathica presents at weaning or in very early infancy, with eczema and blisters of hands, on the feet, and around the mouth and anus, together with progressive hair fall and failure to thrive.
- Linoleic acid, an essential fatty acid, is metabolized to arachidonic acid in the body, which is then converted into prostaglandins and leukotrienes, the mediators that help the body to fight harmful microorganisms. Linoleic acid deficiency occurs due to malabsorption, malnutrition, bypass surgery for obesity and with parenteral nutrition. The upper layer of skin becomes dry, scaly, horny and reddened with brittle nails and capillary fragility. There is diffuse hair loss with pigmentation of the remaining hair.
Signs and symptoms of malabsorption
Non specific skin symptoms
Specific skin symptoms
Glove and stocking hyperpigmentation
Weight loss and wasting
Laboratory diagnosis of malabsorption
The various laboratory tests to diagnose malabsorption include:
- Stool fat analysis
- Xylose absorption
- Gastrointestinal X-ray studies
- Small intestinal biopsy
- Schilling's test for Vitamin-B12 absorption
- Secretin and other pancreatic enzyme tests
- Serum calcium, albumin, cholesterol, magnesium and iron
- Serum carotenes, Vitamin-A levels and Prothrombin time
- Bile acid Breath tests as a screen for Bacterial Overgrowth
Management of malabsorption
To treat malabsorption, treatment of specific causative conditions, along with symptomatic cure is required.
- Individuals suffering from malabsorption should be encouraged to eat several small, frequent meals throughout the day, that are rich in carbohydrates, proteins, fats, minerals and vitamins.
- Persons affected should be monitored for dehydration (dry tongue, increased thirst, low and concentrated urine output, feeling weak or dizzy when standing); low blood pressure; shortness of breath; and fluid volume excess due to diminished protein stores, that may require fluid restriction.
- For specific conditions, management depends on individual causes, as long term antibiotics and folic acid supplements are required for Tropical sprue.
- Antibiotics are needed to treat Whipple's disease.
- Injections of Vitamin-B12 and oral Iron supplements are required for dietary deficiencies.
- Pancreatic supplements are necessary for treatment of diseases of the pancreas.
- Diet modification and avoidance of foods that precipitate symptoms, is required for Lactose intolerance (avoidance of milk and milk based products)and Celiac sprue (avoidance of gluten-containing foods).
The expected course for an individual with malabsorption varies, depending on the cause. Patience and positive attitude are important in controlling or curing the disorder. Careful monitoring is necessary to prevent additional illnesses caused by nutritional deficiencies.