Drs. Bernice Kwong, Rob Novoa, and Silvina Pugliese discuss common nutritional deficiencies in hospitalized and cancer patients, how those might present on the skin, and what dermatologists can do to diagnose and manage these patients.
Bernice Kwong, MD, is Clinical Professor of Dermatology; Rob Novoa, MD, is Clinical Associate Professor of Pathology and Dermatology; and Silvina Pugliese, MD, is Clinical Assistant Professor of Dermatology, Stanford University School of Medicine, Stanford, California
“In sick and hospitalized patients, one of the most important lessons we have learned is that mixed nutritional deficiencies or deficiencies in multiple vitamins are more common than solitary vitamin deficiencies,” said Bernice Kwong, MD, who co-presented “Nutritional Deficiencies in Hospitalized and Cancer Patients,” at the 2022 Annual American Academy of Dermatology (AAD) meeting in Boston.
“When it comes to what actual micronutrients are most commonly deficient in hospitalized patients, vitamins A; many of the B vitamins, including B3 and B6; vitamin C; copper; zinc; and protein are common, but a mixed picture is going to be the most common presentation.”
From decreased intake to malabsorption to increased metabolic demands, cancer patients are predisposed to nutritional deficiencies for many reasons, according to Rob Novoa, MD, who also presented during the session on nutritional deficiencies.
“Patients may have multiple problems. They may have both graft versus host disease and nutritional disease, and one may exacerbate the other,” he said.
Risk factors for nutritional deficiency, which can be unique to hospitalized and cancer patients, include chemotherapy leading to treatment-related gastrointestinal (GI) malabsorption; chronic disease; repeat hospitalizations; type of malignancy; parenteral nutrition lacking micronutrients; loss of appetite caused by depression; and fad “anti-cancer” diets, according to Silvina Pugliese, MD, who also presented during the session.
“Anticancer drugs can lead to nutrient deficiencies in the absence of classic GI malabsorptive symptoms. Don’t let the absence of a symptom like diarrhea dissuade you from pursuing laboratory work-up in a patient who is at risk for and has clinical signs of nutritional deficiency,” said Dr. Pugliese.
“Common skin findings which can be seen in hospitalized and cancer patients with nutritional deficiency include alopecia, seborrheic dermatitis, angular cheilitis, periorificial rash, intertriginous eruptions, perifollicular papules, non-healing wounds, [and] recalcitrant eczematous dermatoses.”
The skin effects of nutritional deficiencies are relevant in sick patients, whether they are in the inpatient or outpatient setting. And they can impact dermatology and non-dermatologic patients, alike, according to Dr. Kwong.
“We have patients with psoriasis, hidradenitis suppurativa, severe atopic dermatitis, or skin ulcers who have chronic disease of their skin where there is a high degree of inflammation and skin turnover, which leads to high demand on the body to use nutrients to restore skin.”
Picking Up on Clues
Predicting where hospitalized patients might be deficient is complicated without objective bloodwork, according to Dr. Kwong.
“As dermatologists, when we learn about vitamin deficiencies and nutritional dermatoses, we traditionally learn about specific patterns from specific vitamin deficiencies. [For example,] vitamin C deficiency causes bruising in a specific pattern. But then when we look at hospitalized and sick patients, because the most common pattern is going to be multiple deficiencies, we will see overlap and there is a lot of overlap between different vitamin deficiencies and how they present in the skin.”
There are, however, some patterns that help dermatologists to have an index of suspicion that there is an existing nutritional deficiency, she said.
“Those include a periorificial rash or dermatitis, angular cheilitis, or other rashes around the eyes, mouth, and genital area that won’t go away. Another common pattern is intertriginous or flexural dermatoses or dermatitis.”
A patient with a highly refractory rash in flexural areas should raise the dermatologist’s suspicion for nutritional dermatosis or deficiency, said Dr. Kwong.
“We also commonly see someone whose skin is really dry and the patient is telling us that they are using moisturizer multiple times a day, yet their skin is desquamating, flaky, and dry despite their greatest efforts and ours. That’s another sign we should be thinking about a concurrent nutritional deficiency in sick and hospitalized patients.”
Any skin condition that is not healing, whether it be a dermatitis, or a skin erosion or ulcer, can be a clue of a possible underlying nutritional deficiency. If a dermatologist thinks they have the right diagnosis and treatment, yet the skin isn’t healing, that can be a clinical clue that a nutritional deficiency may be present, said Dr. Kwong.
One example, according to Dr. Novoa would be “If an allogeneic transplant patient has unusually refractory graft versus host disease, or photosensitivity, or more pronounced scaling than typical, consider nutritional deficiency.”
Diagnosis and Management
Ideally, a dermatologist could look at the skin of hospitalized or cancer patients and know which specific nutrients are deficient in these complex situations, but that’s not the case yet, according to Dr. Kwong.
“Remembering that these patients will most commonly have multiple deficiencies is important; then thinking about using the clinical clues to bring nutritional deficiency to the differential; and then objectively looking at vitamins and micronutrients that are important for skin integrity in their bloodwork, so we objectively know what is low and what is not.”
A biopsy might help, but biopsy findings are subtle, according to Dr. Novoa.
“… we often see parakeratosis, psoriasiform changes, and dyskeratosis at all levels of the epidermis. These findings may be seen in psoriasiform graft versus host disease but may warrant further workup in the correct clinical setting.”
The goal of management and treatment is to supplement only what is needed and avoid over-supplementation or unnecessary supplements, according to Dr. Kwong.
“As dermatologists, we spend a lot of time actually taking our patients off of supplements. In our sickest of patients, our cancer patients, our patients who are suffering from any disease, they are looking for hope, and there is a huge industry selling vitamins and herbs in the name of giving patients hope. But a lot of these supplements can cause rashes, themselves. So, we don’t want to move into that territory of giving them things they don’t need.”
By objectively looking at the bloodwork of skin specific nutrients, dermatologists can target supplementation for the patient, she said.
“When we meet patients—inpatient or outpatient—who have chronic disease, chronic inflammation, where they have a skin condition that is difficult to fix, these are the patients we should be thinking about to make sure they have adequate building blocks to heal their skin. That potentially can help us to heal their skin more successfully,” said Dr. Kwong.
Disclosures: Dr. Kwong consults for Genentech, Novartis, and Oncoderm. Drs. Novoa and Pugliese report no relevant disclosures.
