Dermatological manifestations relating to nutritional deficiencies after bariatric surgery: case report and integrative literature review

Silva, Andressa Christine Ferreira; Kazmarek, Laura Moya; Souza, Elemir Macedo de; Cintra, Maria Letícia; Teixeira, Fernanda

doi:10.1590/1516-3180.2021.0616.R1.17022022

Acessibilidade / Reportar erro

Brasil

Sao Paulo Medical Journal

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review Article • Sao Paulo Med. J. 140 (5) • Sep-Oct 2022 • https://doi.org/10.1590/1516-3180.2021.0616.R1.17022022 copy

Dermatological manifestations relating to nutritional deficiencies after bariatric surgery: case report and integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

The number of bariatric surgeries performed worldwide is growing. Among the main short, medium or long-term complications after surgery are nutritional deficiencies. Many of these, such as those of Zn, Cu and vitamins A, B1, B3, B6 and B12, are manifested by dermatological lesions before potentially fatal systemic disorders occur.

OBJECTIVE:

To identify the main dermatological manifestations associated with nutritional deficiencies after bariatric surgery, and the associated variables.

DESIGN AND SETTING:

Integrative literature review carried out at a public university in Brazil.

METHODS:

This was a case report and a review of health research portals and databases of national and international biomedical journals, without publication date limitation. The descriptors used for searches followed the ideal methodology for each database/search portal: “bariatric surgery”, “skin”, “skin disease”, “skin manifestation”, “deficiency disease” and “malnutrition”.

RESULTS:

A total of 59 articles were selected, among which 23 were review articles or articles that addressed specific dermatological manifestations. The other 36 articles described 41 cases, which were organized into a table with the clinical variables.

CONCLUSIONS:

Although nutritional deficiencies are expected as complications after bariatric surgery, few articles relating them to their dermatological manifestations were found. It is important to recognize skin changes caused by nutritional deficiencies in patients treated via bariatric surgery, as these may occur before systemic complications appear and are easier to diagnose when the patient does not have any systemic symptoms yet. However, there is generally a delay between the appearance of skin lesions and making the diagnosis of nutritional deficiency.

KEY WORDS (MeSH terms):
Bariatric surgery; Skin manifestations; Malnutrition; Skin diseases; Deficiency diseases

AUTHORS’ KEY WORDS:
Xerophthalmias; Phrynoderma; Acrodermatitis enteropathica; Bariatric surgical procedures; Nutritional deficiencies; Dermatopathies

Article (Ref.)	Nutritional deficiency after surgery	Dermatological manifestation	Type of surgery	Age	Sex	Adhered	Time to signs	Rx	Evolution	Systemic manifestations
Lopez et al.⁵²52 Lopez JF, Halimi S, Perillat Y. Erythème pellagroïde après gastroplastie verticale calibrée pour obésité morbide [Pellagra-like erythema following vertical banded gastroplasty for morbid obesity]. Ann Chir. 2000;125(3):297-8. PMID: 10829515; https://doi.org/10.1016/s0001-4001(00)00135-5. https://doi.org/10.1016/s0001-4001(00)00...	Zn	Pellagra-like erythema	VBG	51	F	DNA	5	O + A	Resolved in a few days	U
Bae-Harboe et al.³⁹39 Bae-Harboe YS, Solky A, Masterpol KS. A case of acquired zinc deficiency. Dermatol Online J. 2012;18(5):1. PMID: 22630571; https://doi.org/10.5070/D340w733sk. https://doi.org/10.5070/D340w733sk...	Zn	Acrodermatitis enteropathica acquisita	RYGP	62	M	U	3	O	Resolved in a week	U
Mankaney et al.⁵³53 Mankaney GN, Vipperla K. Images in clinical medicine. Acquired acrodermatitis enteropathica. N Engl J Med. 2014;371(1):67. PMID: 24988559; https://doi.org/10.1056/NEJMicm1312911. https://doi.org/10.1056/NEJMicm1312911...	Zn	Acrodermatitis enteropathica acquisita	RYGP	54	F	A	8	U	Significant improvement	U
Rana et al.⁵⁹59 Rana J, Plovanich M, Wallace EB, et al. Acquired acrodermatitis enteropathica after gastric bypass surgery responsive to IV supplementation. Dermatol Online J. 2016;22(11):13030/qt50v2f3mb. PMID: 28329567; https://doi.org/10.5070/D32211033150. https://doi.org/10.5070/D32211033150...	Zn, Vit. B6, Se, Alb	Acrodermatitis enteropathica acquisita, xerosis, diffuse non-scarring alopecia.	RYGP	39	F	A	13	P	Significant improvement	U
Jacob et al.⁴⁷47 Abstracts from the 2016 Society of General Internal Medicine Annual Meeting. J Gen Intern Med. 2016;31 Suppl 2(Suppl 2):85-922. PMID: 27114361; https://doi.org/10.1007/s11606-016-3657-7. https://doi.org/10.1007/s11606-016-3657-...	Zn, Cu	Erythematous rash on the back and limbs	RYGP	54	M	U	10	P+O	U	Neurological, hematological.
Cunha et al.⁴¹41 Cunha SF, Goncalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J. 2012;130(5):330-5. PMID: 23174873; https://doi.org/10.1590/s1516-31802012000500010. https://doi.org/10.1590/s1516-3180201200...	Zn, Cu, Fe, Alb	Acrodermatitis enteropathica acquisita, xerosis, pruritus	VBG/JIB	30	F	A	0.6	O	Significant improvement	Neurological, hematological
Stephens et al.⁶¹61 Stephens JW, Boregowda K, Barry J, et al. Adrenal insufficiency following bariatric surgery. Obes Rev. 2012;13(6):560-2. PMID: 22385616; https://doi.org/10.1111/j.1467-789X.2012.00987.x. https://doi.org/10.1111/j.1467-789X.2012...	Fe, Vit A + D	Photosensitivity, hair loss, discolored hair.	BPD	30	F	DNA	5	O	U	Endocrinological, neurological, ophthalmological
Boutin et al.⁴⁰40 Boutin D, Cante V, Levillain P, Piguel X, Guillet G. Kwashiorkor chez l'adulte: une complication rare de la chirurgie bariatrique [Adult kwashiorkor: A rare complication of bariatric surgery]. Ann Dermatol Venereol. 2015;142(2):99-103. PMID: 25554665; https://doi.org/10.1016/j.annder.2014.11.006. https://doi.org/10.1016/j.annder.2014.11...	Vit A+B6+B9+D, Alb	Generalized skin pigmentation	RYGP	44	F	DNA	4	O	Resolved	General, hematological
Messenger et al.⁵⁴54 Clinical Vignettes/Case Reports - Small Intestine/Unclassified. Am J Gastroenterol. 2016;111(S1):S971-S1076. PMID: 27685313; https://doi.org/10.1038/ajg.2016.374. https://doi.org/10.1038/ajg.2016.374...	Zn, Vit B3, Alb	Kwashiorkor, cracked eczema-like lesions	RYGP	35	F	U	10	P	Resolved	Hepatic steatosis
Panetta et al.⁵⁷57 Panetta C, Paolino G, Muscardin L, Donati M, Donati P. Biliopancreatic diversion: when a cure becomes a disease. Am J Dermatopathol. 2014;36(3):258-9. PMID: 23719482; https://doi.org/10.1097/DAD.0b013e3182926665. https://doi.org/10.1097/DAD.0b013e318292...	Vit A	Acrodermatitis enteropathica acquisita, eczematous plaques on the limbs	BPD	51	M	U	.	P	Improved, but hyperpigmentation persisted	Ophthalmological
Vallabhaneni et al.⁶⁴64 Abstracts from the 2017 Society of General Internal Medicine Annual Meeting. J Gen Intern Med. 2017;32(Suppl 2):83-808. PMID: 28397154; https://doi.org/10.1007/s11606-017-4028-8. https://doi.org/10.1007/s11606-017-4028-...	Vit A + D	Phrynoderma	VBG/DS	50	F	U	NI	U	U	Polyarthralgia, fever
Wilson et al.⁶⁷67 Wilson HO, Datta DB. Complications from micronutrient deficiency following bariatric surgery. Ann. Clin. Biochem. 2014;51(Pt 6):705-9. PMID: 24847133; https://doi.org/10.1177/0004563214535562. https://doi.org/10.1177/0004563214535562...	Zn, Vit A + D	BADAS (bowel-associated dermatitis-arthritis syndrome). Ulcers and pustules on the limbs.	BPD	40	F	A	6	P+O	Died	Osteoporosis, ophthalmological
Zouridaki et al.⁶⁸68 Zouridaki E, Papafragkaki DK, Papafragkakis H, Aroni K, Stavropoulos P. Dermatological complications after bariatric surgery: report of two cases and review of the literature. Dermatology. 2014;228(1):5-9. PMID: 24401283; https://doi.org/10.1159/000356160. https://doi.org/10.1159/000356160... Case 1	Vit B12 + D	Acrodermatitis enteropathica acquisita, pallor, hair loss, pruritic papular rash on back and limbs.	RYGP	45	F	U	2	P+O	Improved in 3 months	U
Zouridaki et al.⁶⁸68 Zouridaki E, Papafragkaki DK, Papafragkakis H, Aroni K, Stavropoulos P. Dermatological complications after bariatric surgery: report of two cases and review of the literature. Dermatology. 2014;228(1):5-9. PMID: 24401283; https://doi.org/10.1159/000356160. https://doi.org/10.1159/000356160... Case 2	Vit B12	Leg ulcers, round scars on forearms, impetigo-like lesions on the scalp, localized alopecia, angular cheilitis	RYGP	62	F	DNA	8	P	Resolved in 6 months	Hematological
Gillette et al.⁴⁷47 Abstracts from the 2016 Society of General Internal Medicine Annual Meeting. J Gen Intern Med. 2016;31 Suppl 2(Suppl 2):85-922. PMID: 27114361; https://doi.org/10.1007/s11606-016-3657-7. https://doi.org/10.1007/s11606-016-3657-...	Vit B1, B3, Alb, Fe	Large abscesses and ulcers on lower limbs	RYGP	47	F	U	10	BR+O	Improved in a year.	Neurological
Ashourian et al.³⁸38 Ashourian N, Mousdicas N. Images in clinical medicine. Pellagra-like dermatitis. N Engl J Med. 2006;354(15):1614. PMID: 16611952; https://doi.org/10.1056/NEJMicm050641. https://doi.org/10.1056/NEJMicm050641...	Zn, Vit B3, B6	Kwashiorkor, thinning hair, xerosis on the trunk, hyperpigmented, macular rash	RYGP	32	F	U	0.3	O	Significant improvement in 4 weeks	None
Katugampola et al.⁴⁹49 Katugampola RP, Patel GK, Farrell AM. Intestinal bypass syndrome presenting as erythema nodosum. Clin Exp Dermatol. 2004;29(3):261-4. PMID: 15115506; https://doi.org/10.1111/j.1365-2230.2004.01476.x. https://doi.org/10.1111/j.1365-2230.2004...	Vit A, D, E, K	Acrodermatitis enteropathica acquisita, pellagra	JIB/GJ	66	F	DNA	12	BR	Resolved, but died after 7 months.	CKD, arthropathy, anemia
Vick et al.⁶⁶66 Vick G, Mahmoudizad R, Fiala K. Intravenous zinc therapy for acquired zinc deficiency secondary to gastric bypass surgery: a case report. Dermatol Ther. 2015;28(4):222-5. PMID: 25754007; https://doi.org/10.1111/dth.12209. https://doi.org/10.1111/dth.12209...	Zn, Cu	Erythema nodosum	RYGP	38	F	A	10	P	Significant improvement	U
Jaffe et al.⁴⁸48 Jaffe AT, Heymann WR. Kwashiorkor/zinc deficiency overlap following partial gastrectomy. Int J Dermatol. 1998;37(2):134-7. PMID: 9542673; https://doi.org/10.1046/j.1365-4362.1998.00374.x. https://doi.org/10.1046/j.1365-4362.1998...	Zn, Alb	Acrodermatitis enteropathica acquisita	GJ/SS	48	F	U	16	U	U	Gastrointestinal, malnutrition, coma
Garg et al.⁴⁶46 Clinical Vignettes/Case Reports-Obesity. Am J Gastroenterol. 2017;112(S1):S1293-S1297. PMID: 28981039; https://doi.org/10.1038/ajg.2017.322. https://doi.org/10.1038/ajg.2017.322... Case A	Zn, Vit A, Cu, Alb	Kwashiorkor, cheilitis, “cracked enamel” appearance on buttocks, thighs, and arms	RYGP	60	F	U	9	P	Died	Weakness, gastrointestinal.
Garg et al.⁴⁶46 Clinical Vignettes/Case Reports-Obesity. Am J Gastroenterol. 2017;112(S1):S1293-S1297. PMID: 28981039; https://doi.org/10.1038/ajg.2017.322. https://doi.org/10.1038/ajg.2017.322... Case B	Zn, Cu	Acrodermatitis enteropathica acquisita	RYGP	46	F	U	10	P	Significant improvement	Weakness, neurological, gastrointestinal.
Shackelton et al.⁶⁰60 Shackelton JB, Chabra IS, Liu JC, Swoger JM, Grandinetti LM. Nutritional dermatoses in the bariatric surgery patient. Internal Medicine Dermatology. 2012;66(4 Suppl 1):AB132. https://doi.org/10.1016/j.jaad.2011.11.558. https://doi.org/10.1016/j.jaad.2011.11.5... Case 1	Zn, Cu, Vit A	Kwashiorkor, hair loss	RYGP	36	F	U	10	U	Resolved	U
Shackelton et al.⁶⁰60 Shackelton JB, Chabra IS, Liu JC, Swoger JM, Grandinetti LM. Nutritional dermatoses in the bariatric surgery patient. Internal Medicine Dermatology. 2012;66(4 Suppl 1):AB132. https://doi.org/10.1016/j.jaad.2011.11.558. https://doi.org/10.1016/j.jaad.2011.11.5... Case 2	Zn	Acrodermatitis enteropathica acquisita	RYGP	45	F	U	0.7	U	Resolved, but intertrigo persisted.	U
Shackelton et al.⁶⁰60 Shackelton JB, Chabra IS, Liu JC, Swoger JM, Grandinetti LM. Nutritional dermatoses in the bariatric surgery patient. Internal Medicine Dermatology. 2012;66(4 Suppl 1):AB132. https://doi.org/10.1016/j.jaad.2011.11.558. https://doi.org/10.1016/j.jaad.2011.11.5... Case 3	Zn, Cu, Vit A, B3	Acrodermatitis enteropathica acquisita	RYGP	32	F	U	3	U	Resolved	U
Garcovich et al.⁴⁵45 Garcovich S, Di Stefani A, Capizzi R, Massi G, Peris K. Occurrence of hidradenitis suppurativa and phrynoderma after bariatric surgery. J Eur Acad Dermatol Venereol. 2016;30(7):1215-7. PMID: 25879252; https://doi.org/10.1111/jdv.13140. https://doi.org/10.1111/jdv.13140...	Zn, Fe, Vit D	Acrodermatitis enteropathica acquisita	BPD/DS	47	M	A	2	U	U	Endocrinological
Levenbergh et al.⁵¹51 Abstracts presented at the 22nd Annual Congress of the Belgian Society of Internal Medicine, 15-16 December 2017, Dolce La Hulpe, La Hulpe, Belgium. Acta Clin Belg. 2017;72(sup2):1-56. PMID: 29198176; https://doi.org/10.1080/17843286.2017.1401314. https://doi.org/10.1080/17843286.2017.14...	Vit B3, C, Alb	Hidradenitis suppurativa; phrynoderma	RYGP	58	F	U	1	O	Resolved in a few days	Gastrointestinal
Abad et al.³⁵35 Abad L, Omiste T, Vera J, Gilaberte Y. Phrynoderma after biliopancreatic diversion. Actas Dermosifiliogr. 2015;106(4):327-9. PMID: 25456111; https://doi.org/10.1016/j.ad.2014.08.009. https://doi.org/10.1016/j.ad.2014.08.009...	Zn, Vit A, D3, E	Pellagra	BPB	46	M	A	13	O+P	Resolved in 10 months	Hematological
Ocon et al.⁵⁶56 Ocón J, Cabrejas C, Altemir J, Moros M. Phrynoderma: a rare dermatologic complication of bariatric surgery. JPEN J Parenter Enteral Nutr. 2012;36(3):361-4. PMID: 22269897; https://doi.org/10.1177/0148607111422067. https://doi.org/10.1177/0148607111422067...	Vit A, D, Fe	Phrynoderma	BPD	54	M	DNA	1	O+P	Resolved in 2 months but hyperpigmentation persisted	Osteoarticular, gastrointestinal, ophthalmological
Monshi et al.⁵⁵55 Monshi B, Stockinger T, Vigl K, et al. Phrynoderma and acquired acrodermatitis enteropathica in breastfeeding women after bariatric surgery. J Dtsch Dermatol Ges. 2015;13(11):1147-54. PMID: 26513075; https://doi.org/10.1111/ddg.12795. https://doi.org/10.1111/ddg.12795... Case 1	Zn, Vit A, D, E, Alb	Phrynoderma	RYG	31	F	U	4	P	Improvement in 5 months	U
Monshi et al.⁵⁵55 Monshi B, Stockinger T, Vigl K, et al. Phrynoderma and acquired acrodermatitis enteropathica in breastfeeding women after bariatric surgery. J Dtsch Dermatol Ges. 2015;13(11):1147-54. PMID: 26513075; https://doi.org/10.1111/ddg.12795. https://doi.org/10.1111/ddg.12795... Case 2	Zn, Vit A, B9, D	Phrynoderma; sharply demarcated perianal scaly plaques.	RYGP	29	F	U	7	P	Resolved in 7 days	U
Khanal et al.⁵⁰50 Khanal S, Ghimire P, Bhat U, et al. 1695: Reversal of coma and MRI findings on correction of bariatric surgery-associated hyperammonemia. Crit Care Med. 2016;44(12):499. https://doi.org/10.1097/01.ccm.0000510368.81422.93. https://doi.org/10.1097/01.ccm.000051036...	Zn	Acrodermatitis enteropathica acquisita	RYGP	45	F	A	0.1	P	U	Coma
Al Alawi et al.³⁶36 IFSO 2017 22nd World Congress. Obes Surg. 2017;27(Suppl 1):1-1253. PMID: 28646415; https://doi.org/10.1007/s11695-017-2774-7. Erratum in: Obes Surg. 2017. https://doi.org/10.1007/s11695-017-2774-...	U	Facial and extremity macular rash	LOLGB	40	F	U	2	BR	U	U
Ramos-Levi et al.⁵⁸58 Ramos-Leví AM, Pérez-Ferre N, Sánchez-Pernaute A, Torres García AJ, Rubio Herrera MA. Severe vitamin A deficiency after malabsorptive bariatric surgery. Nutr Hosp. 2013;28(4):1337-40. PMID: 23889662; https://doi.org/10.3305/nh.2013.28.4.6610. https://doi.org/10.3305/nh.2013.28.4.661...	Zn, Vit A, D, E, Se, Cu, Alb	Hair loss, dry, pale skin.	RYGP/DS	48	F	A	2	BR	Improvement in 6 months	Ophthalmological, gastrointestinal
Velazquez et al.⁶⁵65 Velazquez A, Apovian CM, Istfan NW. The Complexities of Iron Deficiency in Patients After Bariatric Surgery. Am J Med. 2017;130(7):e293-e294. PMID: 28238687; https://doi.org/10.1016/j.amjmed.2017.01.040. https://doi.org/10.1016/j.amjmed.2017.01...	Fe	Xerosis; eczema and pruritus on back and limbs.	RYGP	34	F	A	0.3	O	Improvement in 3 months	Neurological
Vales-Montero et al.⁶³63 Vales Montero M, Chavarría Cano B, Martínez Ginés ML, et al. Deficiencia clínica de vitamina A tras bypass gástrico. Descripción de un caso clínico y revisión de la literatura [Clinical vitamin A deficiency after gastric bypass. Description of a clinical case and review of the literature]. Nutr Hosp. 2016;33(4):404. PMID: 27571679; https://doi.org/10.20960/nh.404. https://doi.org/10.20960/nh.404...	Vit A, B12, D	Hair loss	RYGP	40	M	DNA	5	P	Improvement in 3 months	Ophthalmological
Al-Douri et al.³⁷37 Al-Douri A, Chambers J, John J. Nutritional deficiencies in a patient with Roux-en-Y gastric bypass surgery. American Journal of Gastroenterology. 2019;114:S1535. https://doi.org/10.14309/01.ajg.0000600640.63227.f1. https://doi.org/10.14309/01.ajg.00006006...	Zn, Cu	Papulosquamous lesions on limbs	RYGP	41	F	U	5	O	U	Gastrointestinal, osteoarticular, neurological
Evans et al.⁴²42 Evans JB, Hastings JG, Kaffenberger BH. Acquired Pili Torti. JAMA Dermatol. 2019;155(4):488. PMID: 30810707; https://doi.org/10.1001/jamadermatol.2018.4677. https://doi.org/10.1001/jamadermatol.201...	Zn, Cu	Hyperpigmentation of forehead, upper back, and upper arms	RYGP	40	F	U	NI	U	U	Steatohepatitis
Freitas et al.⁴³43 Freitas J, Bliven P, Case R. Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass. BMJ Case Rep. 2019;12(8):e230605. PMID: 31377720; https://doi.org/10.1136/bcr-2019-230605. https://doi.org/10.1136/bcr-2019-230605...	Zn, Vit A, B1, B6, C	Acrodermatitis enteropathica acquisita, pili torti, hair loss with short, brittle, lusterless hair.	RYGP	39	F	A	6	P	Significant improvement in 14 days	Neurological
Garcia et al.⁴⁴44 Garcia D, Nielson CB, Gillihan R, et al. Xerotic Eruption and Purpura: Answer. Am J Dermatopathol. 2020;42(3):221-3. PMID: 32079821; https://doi.org/10.1097/DAD.0000000000001323. https://doi.org/10.1097/DAD.000000000000...	Zn, Vit B1, B6, C, Alb	Acrodermatitis enteropathica acquisita	RYGP	39	F	U	4	U	U	U
Sung et al.⁶²62 Abstracts from the 2019 Annual Meeting of the Society of General Internal Medicine. J Gen Intern Med. 2019;34(Suppl 2):99-867. PMID: 31090026; https://doi.org/10.1007/s11606-019-05007-5. https://doi.org/10.1007/s11606-019-05007...	Zn	Acrodermatitis enteropathica acquisita. Eczema craquelé-like plaques.	RYGP	35	F	U	4	O	U	Hepatic
Wang et al.²⁵25 24th IFSO World Congress. Obes Surg. 2019;29(Suppl 5):347-1720. PMID: 31350717; https://doi.org/10.1007/s11695-019-04101-1. https://doi.org/10.1007/s11695-019-04101...	Zn	Palpable, painful purpuric rash on lower trunk and limbs. Desquamation of the dorsa of feet.	RYGP	37	F	U	5	P	Resolved	Gastrointestinal

Associação Paulista de Medicina - APM APM / Publicações Científicas, Av. Brigadeiro Luís Antonio, 278 - 7º and., 01318-901 São Paulo SP - Brazil, Tel.: +55 11 3188-4310 / 3188-4311, Fax: +55 11 3188-4255 - São Paulo - SP - Brazil
E-mail: revistas@apm.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Address for correspondence: Maria Letícia Cintra Departamento de Patologia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP) R. Tessália Vieira de Camargo, 126 Cidade Universitária “Zeferino Vaz” — Campinas (SP) — Brasil. CEP 13083-887 Tel./Fax. (+55 19) 3289-3897 E-mail: marialet@fcm.unicamp.br