eMedicine Specialties > Pediatrics: General Medicine > Nutrition

Carotenemia

Updated: Jul 16, 2009

Introduction

Background

Carotenemia is a clinical condition characterized by yellow pigmentation of the skin and increased beta-carotene levels in the blood. In most cases, the condition follows prolonged and excessive consumption of carotene-rich foods, such as carrots, squash, and sweet potatoes. However, carotenemia has been associated with more serious conditions, such as diabetes mellitus, anorexia nervosa, liver disease, kidney disease, and hypothyroidism. Carotene was first isolated in the yellow pigment of carrots.

Carotenoderma visible on nasolabial folds.

Pathophysiology

Carotenoids are pigments of plant origin and are responsible for the yellow and orange color of fruits and vegetables. Carotenoids act as antioxidants, affect cell growth regulation, and modulate gene expression and immune response. Animals are incapable of synthesizing carotenoids. Carotenes are the hydrocarbon component of carotenoids. Carotene derived from plant foods is the primary source of dietary vitamin A. Ingested carotenes, enclosed as crystals or amorphous solids within vegetable cells, are converted to vitamin A in the mucosal cells of the small intestine.

Approximately 10% of ingested carotene is absorbed unchanged and is carried directly to the liver by portal circulation. Factors influencing the absorption of carotene include the fiber content of the plant and the particulate size of the food. Pancreatic lipase, bile acids, fat, and, possibly, thyroid hormone aid in the absorption of carotene. Cooking, pureeing, or mashing fruits and vegetables ruptures cell membranes, thereby increasing the bioavailability of carotene for absorption. Consumption of mashed or pureed food, which is common in infants, may account for an increased incidence of diet-induced carotenemia. Intestinal disease and infections may impair the absorption of carotene. Ingestion of mineral oil decreases absorption, whereas water dispersion agents enhance absorption.

Carotene is excreted through the colon and epidermis. In the latter area, the horny layer of skin reabsorbs carotene if excretion is unusually heavy. In fact, carotenoids accumulate in the epidermis about 2 weeks after serum levels achieve equilibrium, and maximum accumulation occurs in areas with an abundance of sweat glands, such as the nasolabial folds, palms, and soles.

Carotene does not readily cross the placenta but is found in high concentrations in human milk. Consequently, infants who are breastfeeding have higher serum levels of carotene than infants fed with formula.

Excessive dietary intake of carotene-rich food is, by far, the most common cause of carotenemia. In rare cases, carotenemia results from systemic disease. This article focuses primarily on diet-induced carotenemia.

Frequency

United States

No data are available.

Mortality/Morbidity

Diet-induced carotenemia is a benign condition that is not associated with complications. Discoloration of the skin remits with dietary modification.

Race

Predilection is unknown.

Sex

No predilection is observed.

Age

Diet-induced carotenemia is observed most frequently in infants and young children.

Clinical

History

Constitutional symptoms, such as itching, malaise, and weight loss, are characteristically absent in children with diet-induced carotenemia.
A history of excessive ingestion of carotene-rich foods is often present. Carotene-rich foods include asparagus, broccoli, carrots, cucumbers, lettuce, spinach, squash, sweet potatoes, apples, oranges, peaches, prunes, tomatoes, yams, butter, egg yolks, milk, and yellow corn.
Children may present with symptoms specific to one of the rare causes of carotenemia rather than carotenemia that is diet-induced. Such symptoms might include pruritus, fatigue, abdominal pain, and weight loss.

Physical

Carotenemia is characterized by a yellow pigmentation of the skin that is more pronounced under artificial light.
Because carotene is excreted by sebaceous glands and is present in sweat, the yellow pigmentation is particularly noticeable in areas where sweating is marked.
Yellow pigmentation often appears first on the tip of the nose, palms, soles, and nasolabial folds, extending gradually over the entire body. However, the yellow pigmentation is most prominently displayed on the palms, soles, and nasolabial folds. The pigmentary change results from deposition of carotene in the fat-soluble stratum corneum.
The sclerae are always spared, which readily distinguishes carotenemia from jaundice; however, carotenemia occasionally may present with coloration of the palate. Note that the conjunctivae and oral mucosa are areas lacking stratum corneum.
Children who present with rare causes of carotenemia that are not related to diet may have physical signs specific to that disease process.

Causes

Carotene consumption
- Excessive consumption of carotene-rich foods is the most common cause of carotenemia.
- Carotenes occur in all pigmented fruits and vegetables, and they are synthesized as fruits and vegetables ripen.
- In green vegetables, the color of carotene is often masked by the green color of chlorophyll. As a rule of thumb, the deeper the green or yellow of a fruit or vegetable, the more carotene it contains.
- Although often overlooked by parents, most strained baby foods on the market contain carrots.
- Human and cow milk also contain carotene. The occasional yellow color of milk is due to carotene content, and human milk provides a rich source of carotene, especially if maternal serum carotene levels are high.
- The yellow color of colostrum is caused by carotene content.
- In dietary carotenemia, elevated serum carotene often is accompanied by a corresponding elevation in serum vitamin A levels, but hypervitaminosis A is not observed presumably because the conversion of carotenoids to vitamin A is regulated. In other causes of carotenemia, serum vitamin A levels are within reference ranges or low.
Diabetes mellitus
- Many individuals with diabetes have elevated serum carotene levels, but only 10% of these individuals exhibit yellowing of the skin.
- Carotenemia may be related to restricted dietary habits, hyperlipidemia, or a deficiency in the conversion of carotene into vitamin A by the liver.
Hypothyroidism
- The commonly accepted cause of carotenemia in hypothyroidism is a decrease in the conversion of carotene into vitamin A, as well as associated hyperlipidemia and hypercholesterolemia.
- Thyroid hormone is antagonistic to vitamin A and controls its rate of consumption. In hypothyroidism, the consumption of vitamin A is decelerated, and the rate of conversion from carotene to vitamin A is reduced.
Anorexia nervosa
- The association between carotenemia and anorexia nervosa is well documented.
- Carotenemia is not thought to be associated with a high-carotene diet but may be related to hypercholesterolemia, which is an occasional but reversible defect in the conversion of carotene to vitamin A, or to a normal intake of dietary carotene in the presence of a decreased requirement.
Liver disease: Primary hepatic injury may prevent the conversion of carotene to vitamin A.
Kidney disease: Serum carotene levels may markedly be elevated in patients with chronic glomerulonephritis and nephrotic syndrome.
Inborn errors of metabolism: Carotenemia may result from a failure to convert carotene into vitamin A due to an inborn error of metabolism.
Familial conditions: These may be associated with carotenemia.

Differential Diagnoses

Jaundice, Neonatal

Workup

Laboratory Studies

Laboratory studies are not generally indicated in the evaluation of diet-induced carotenemia.
If measured, serum carotene levels are elevated, ranging between 250-500 µg/dL. Multiple authors have reported wide variations in reference range values of serum carotene, making the interpretation of such values difficult.

Treatment

Medical Care

Treatment of diet-induced carotenemia primarily consists of reassuring caretakers that the child with the condition is not at risk for any serious complications.
If parental anxiety is high, eliminating carotene-rich foods from the child's diet can treat carotenemia. With elimination of the intake of carotene-rich foods, serum carotene levels drop sharply within a week and the yellow discoloration of the skin gradually disappears over several weeks to months.
Other causes of carotenemia are extremely rare in children. When suspected, direct appropriate investigation and treatment toward the underlying etiology.

Diet

Children can be placed on a carotene-deficient diet.

Activity

No restrictions are necessary.

Medication

Medications are not indicated for the treatment of diet-induced carotenemia.

Follow-up

Further Outpatient Care

Outpatient follow-up of the patient with diet-induced carotenemia is not required.

Complications

Complications are rare with diet-induced carotenemia.
Vitamin A poisoning does not occur despite even massive doses of carotene because the conversion of carotene to vitamin A occurs slowly.

Prognosis

Carotenemia caused by dietary excess is considered benign and harmless.

Patient Education

Reassure parents that diet-induced carotenemia is a benign condition that requires no treatment. If extreme parental anxiety is present, physicians can inform parents which foods are rich in carotene, and the child can be placed on a carotene-deficient diet.
Inform parents that many green vegetables, such as spinach and green beans, are rich in carotene.¹

Miscellaneous

Medicolegal Pitfalls

A potential medicolegal pitfall would be misidentifying jaundice due to an organic cause as diet-induced carotenemia.

Multimedia

Media file 1: Carotenoderma visible on nasolabial folds.

References

Sale TA, Stratman E. Carotenemia associated with green bean ingestion. Pediatr Dermatol. Nov-Dec 2004;21(6):657-9. [Medline].
Arya V, Grzybowski J, Schwartz RA. Carotenemia. Cutis. Jun 2003;71(6):441-2, 448. [Medline].
Karthik SV, Campbell-Davidson D, Isherwood D. Carotenemia in infancy and its association with prevalent feeding practices. Pediatr Dermatol. Nov-Dec 2006;23(6):571-3. [Medline].
Lascari AD. Carotenemia. A review. Clin Pediatr (Phila). Jan 1981;20(1):25-9. [Medline].
LaVoo EJ, Paller AS. Common skin problems during the first year of life. Pediatr Clin North Am. Oct 1994;41(5):1105-19. [Medline].
Leung AK. Carotenemia. Adv Pediatr. 1987;34:223-48. [Medline].
Nishimura T. A correlation between carotenemia and biliary dyskinesia. J Dermatol. May 1993;20(5):287-92. [Medline].
Rock CL. Carotenoids: biology and treatment. Pharmacol Ther. Sep 1997;75(3):185-97. [Medline].
Schwenk TL, Byrne WJ, Smith MA. Carotenemia. Am Fam Physician. Jul 1987;36(1):135-6. [Medline].
Takita Y, Ichimiya M, Hamamoto Y, Muto M. A case of carotenemia associated with ingestion of nutrient supplements. J Dermatol. Feb 2006;33(2):132-4. [Medline].

Keywords

carotenemia, yellow pigmentation of the skin, beta-carotene, elevated beta-carotene levels, carotene-rich foods, yellow pigment in carrots, carotenoids, dietary vitamin A, diet-induced carotenemia, excessive consumption of carotene-rich foods, diabetes mellitus, hypothyroidism, anorexia nervosa, liver disease, kidney disease, inborn errors of metabolism, xanthemia, carotinemia, carotene, elevated serum carotene, diet-induced carotenemia, asparagus, broccoli, carrots, cucumbers, lettuce, spinach, squash, sweet potatoes, apples, oranges, peaches, prunes, tomatoes, yams, butter, egg yolks, milk, yellow corn, anorexia nervosa, treatment, diagnosis

Contributor Information and Disclosures

Author

Raymond D Pitetti, MD, MPH, Associate Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine; Consulting Staff, University of Pittsburgh Physicians
Raymond D Pitetti, MD, MPH is a member of the following medical societies: Allegheny County Medical Society, American Academy of Pediatrics, Pennsylvania Medical Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia
Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jatinder Bhatia, MBBS, Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia
Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Federation for Clinical Research, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, New York Academy of Sciences, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Mead Johnson Consulting fee Consulting; Mead Johnson Honoraria Speaking and teaching; Dey LP Consulting fee Consulting; Dey LP Honoraria Speaking and teaching; Ovation Honoraria Speaking and teaching

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Further Reading