Dermatologic Manifestations of Vitamin A Deficiency Clinical Presentation

Updated: Mar 26, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
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Presentation

History

Avitaminosis A generally accompanies states of severe malnutrition, such as kwashiorkor and marasmus, and may be suspected in individuals with an unusual susceptibility to infectious diseases, such as measles. Bitot spots, dry eyes, and night blindness strongly point to vitamin A deficiency. [20] Note the following:

  • Impaired vision, particularly at night: Because of the essential role of vitamin A in photoreceptor function, night blindness is the earliest and most common symptom of its deficiency.

  • Xerophthalmia: VAD may produce xerophthalmia. Its ocular manifestations include conjunctival and corneal xerosis (drying), keratomalacia (corneal necrosis/ulceration), nyctalopia (night blindness), and Bitot spots (conjunctival lesions). [4] Maternal night blindness is common during pregnancy in poor countries. Maternal night blindness during pregnancy has been associated with low birthweight, morbidity, and poor growth in South India. [21]

  • Photophobia

  • Erythema

  • Dry, thickened skin (toad skin)

  • Diarrhea

  • Recent history of biliopancreatic diversion bariatric surgery, with phrynoderma and ocular symptoms rarely noted [22, 23]

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Physical Examination

The most distinctive clinical features of VAD are present in the ocular system; however, numerous skin findings have also been reported.

Conjunctival xerosis is typically found on the temporal, interpalpebral, and bulbar conjunctivae. Characteristically, it is seen as a dry, granular patch that can exhibit thickening, wrinkling, loss of pigmentation, and transparency.

Bitot spots are triangular, perilimbal, gray plaques of keratinized conjunctival debris overlying an area of conjunctival xerosis. See the image below. Use of a Wood lamp (a blacklight or ultraviolet-A light) may aid in detecting Bitot spots. [24]

Bitot spots caused by vitamin A deficiency. Courte Bitot spots caused by vitamin A deficiency. Courtesy of the Centers for Disease Control and Prevention Nutrition Program via Wikimedia Commons.

Xerophthalmia results from instability of the precorneal tear film, which can lead to a dull corneal appearance and a superficial punctate keratopathy noted with the use of fluorescein.

Corneal ulcerations can be partial or full thickness. Keratomalacia is a full-thickness liquefactive necrosis of the cornea. Clinically, it is a sharply demarcated lesion with an opaque, grayish yellow appearance. The stroma can slough, either leaving a descemetocele or, in severe cases, causing perforation and loss of the anterior chamber.

Generalized xerosis with fine wrinkles and scales may be present.

Phrynoderma (follicular hyperkeratosis) is characterized by red-brown follicular papules that are approximately 2-6 mm in diameter, with a central keratotic spinous plug. These lesions are usually found clustered around the bony prominences of the elbows and the knees, although they may extend up the thighs and the arms.

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Complications

Note the following possible complications:

  • Acute gastroenteritis

  • Growth retardation

  • Infections

  • Vitamin A toxicity (secondary to treatment)

An association between pediatric pseudotumor cerebri and low serum vitamin A levels has been observed even when other manifestations of xerophthalmia are not evident. [25]

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