Case and Research Letter
Phrynoderma After Biliopancreatic Diversion
Frinoderma asociado a derivación biliopancreática
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Abad, T. Omiste, J. Vera, Y. Gilaberte" "autores" => array:4 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Abad" "email" => array:1 [ 0 => "laura.abad.polo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "T." "apellidos" => "Omiste" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Vera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Y." "apellidos" => "Gilaberte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Medicina de Familia y Comunitaria, Hospital San Jorge, Huesca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital San Jorge, Huesca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital San Jorge, Huesca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital San Jorge, Huesca, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Frinoderma asociado a derivación biliopancreática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 598 "Ancho" => 1600 "Tamanyo" => 180795 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Violaceous, suppurating papular and tuberose lesions, some with scabs. B, Resolution of the phrynoderma lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Current surgical techniques for the treatment of morbid obesity can lead to major systemic complications. Biliopancreatic bypass surgery is a mixed restrictive-malabsorptive type of bariatric surgery that combines partial gastrectomy with a gastroileal anastomosis, causing the bile and pancreatic secretions to mix with the foods only in the final 50<span class="elsevierStyleHsp" style=""></span>cm of the small bowel. In the long term, this considerably reduces the absorption of vitamins, oligoelements, and essential fatty acids.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a man of 46 years of age, with a history of obesity, hypertension, tuberculous lymphadenitis in 2005, a biliopancreatic bypass operation in 1999, and operations for an anal fistula and to perform dermolipectomy in the hypogastrium and flanks. He was on treatment with valsartan, venotonic agents, ferrous sulfate, and Dayamineral (a vitamin and mineral supplement). He was seen in dermatology in 2012 for suppurating lesions on the lower limbs. The lesions had appeared when he started to lose weight after the bariatric surgery and they had gradually spread to the trunk and upper limbs. The diagnoses from 2 skin biopsies performed in 2003 were folliculitis and furuncle, respectively. Cultures for bacteria, fungi, and mycobacteria were repeatedly negative and various oral antibiotic treatments did not resolve the condition. On physical examination there were violaceous papular and tuberose lesions, some with scabs, situated mainly on the thighs and on the medial aspect of the knees, but with isolated lesions on the abdomen and on the proximal areas of the upper limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Histopathology revealed the presence of intense hyperkeratosis in the pilosebaceous follicles, giving rise to the formation of keratin cysts. There was also a small abscess with residues of fragmented collagen and the presence of macrophages and neutrophils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No fragmentation of elastic fibers was detected. Special techniques did not reveal the presence of fungi or of mycobacteria. A provisional diagnosis of phrynoderma was made based on these findings. Blood tests confirmed the deficit of vitamin A (0.15<span class="elsevierStyleHsp" style=""></span>mg/L [normal range, 0.30-1<span class="elsevierStyleHsp" style=""></span>mg/L]), as well as of vitamin E (4.9<span class="elsevierStyleHsp" style=""></span>μg/mL [normal range, 5-20<span class="elsevierStyleHsp" style=""></span>μg/mL]), Vitamin D<span class="elsevierStyleInf">3</span> (14.18<span class="elsevierStyleHsp" style=""></span>ng/mL [normal range, 20-32<span class="elsevierStyleHsp" style=""></span>ng/mL]), and zinc (43<span class="elsevierStyleHsp" style=""></span>μg/dL), as well as a low hemoglobin level (11.4<span class="elsevierStyleHsp" style=""></span>g/dL) and low hematocrit 34%. Oral treatment was therefore prescribed as follows: vitamin A (1000<span class="elsevierStyleHsp" style=""></span>IU/d); vitamin E (20<span class="elsevierStyleHsp" style=""></span>mg/d); calcifediol (1 ampoule of 3<span class="elsevierStyleHsp" style=""></span>mg/1.5<span class="elsevierStyleHsp" style=""></span>mL per week); Hidroxil-B<span class="elsevierStyleInf">12</span>-B<span class="elsevierStyleInf">6</span>-B<span class="elsevierStyleInf">1</span>; Dayamineral, 1 tablet once a day; ferrous iron (80<span class="elsevierStyleHsp" style=""></span>mg/d); and oil rich in medium-chain triglycerides. After 7 months of treatment the skin lesions had not improved and the serum levels of vitamin A (0.11<span class="elsevierStyleHsp" style=""></span>mg/L) and vitamin E (5.1<span class="elsevierStyleHsp" style=""></span>μg/mL), Zn (52<span class="elsevierStyleHsp" style=""></span>μg/dL), the hemoglobin level (11.0<span class="elsevierStyleHsp" style=""></span>g/dL), and the hematocrit 33% were still low. Intravenous iron (500<span class="elsevierStyleHsp" style=""></span>mg of iron), intramuscular vitamin A (100 000<span class="elsevierStyleHsp" style=""></span>IU/mo) and zinc sulfate (22.5<span class="elsevierStyleHsp" style=""></span>mg/d) were therefore added to the patient's treatment. Three months later the vitamin levels were normal (vitamin A, 0.38<span class="elsevierStyleHsp" style=""></span>mg/L), the anemia had resolved, and only residual areas of hyperpigmentation were present on the skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Phrynoderma is the characteristic dermatosis associated with a deficiency of vitamin A, a fat-soluble vitamin involved in numerous body functions. Although this vitamin deficiency is common in Africa and southeast Asia, phrynoderma is rare in Spain, where it is associated with malabsorptive states, such as pancreatic insufficiency, colectomy, and chronic giardiasis, or arises as a complication of bariatric surgery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Vitamin A deficiency is very common among patients who have undergone bariatric surgery and it has been associated with low prealbumin levels, leading to a suggestion to use vitamin A levels as a marker of protein-energy malnutrition in these patients.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Phrynoderma is characterized by the presence of follicular hyperkeratosis, mainly affecting the extensor surfaces of the limbs, the abdomen, and back. It is often associated with xerosis and hyperpigmentation, as well as extracutaneous manifestations such as night blindness. The majority of reports of phrynoderma secondary to biliopancreatic bypass surgery describe atypical lesions that are larger and more inflammatory and tend to arise in atypical sites, as occurred in our patient.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Deficits of many other essential oligoelements and vitamins observed in these patients may contribute to this atypical presentation, particularly if we consider that phrynoderma does not appear to have a single etiology.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> For example, furunculosis has been described in association with iron deficiency and has improved after restoring normal iron levels<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>; this diagnosis had to be considered in our patient as the first biopsies were compatible with this skin disorder.</p><p id="par0030" class="elsevierStylePara elsevierViewall">From a clinical point of view, the differential diagnosis must include other skin conditions that have been described in association with bariatric surgery, such as dermatosis-arthritis syndrome, neutrophilic dermatosis attributed to the formation of circulating immune complexes produced in the blind loop of bowel,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> and acrodermatitis related to zinc deficiency.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> We also considered the perforating dermatoses, although no association with bariatric surgery has been reported.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The increase in obesity in western society means that bariatric surgery will become more common. The conclusion from the present case is that patients undergoing bariatric surgery must be followed up closely by a multidisciplinary team that is aware of the nutritional risks and complications, as well as the appropriate therapeutic strategies that patients must follow for life.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Abad L, Omiste T, Vera J, Gilaberte Y. Frinoderma asociado a derivación biliopancreática. Actas Dermosifiliogr. 2015;106:327–329.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 598 "Ancho" => 1600 "Tamanyo" => 180795 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Violaceous, suppurating papular and tuberose lesions, some with scabs. B, Resolution of the phrynoderma lesions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 741 "Ancho" => 990 "Tamanyo" => 257745 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dilation of the follicular infundibulum with central keratotic plugs (hematoxylin and eosin, original magnification x<span class="elsevierStyleHsp" style=""></span>20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biliopancreatic diversion: When a cure becomes a disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. 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Roselino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sao Paulo Med J" "fecha" => "2012" "volumen" => "130" "paginaInicial" => "330" "paginaFinal" => "335" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23174873" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010600000004/v2_201505051007/S157821901500061X/v2_201505051007/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010600000004/v2_201505051007/S157821901500061X/v2_201505051007/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901500061X?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 88 | 39 | 127 |
| 2024 September | 97 | 18 | 115 |
| 2024 August | 96 | 69 | 165 |
| 2024 July | 102 | 37 | 139 |
| 2024 June | 96 | 34 | 130 |
| 2024 May | 78 | 28 | 106 |
| 2024 April | 77 | 27 | 104 |
| 2024 March | 94 | 32 | 126 |
| 2024 February | 68 | 28 | 96 |
| 2024 January | 68 | 36 | 104 |
| 2023 December | 99 | 20 | 119 |
| 2023 November | 91 | 19 | 110 |
| 2023 October | 86 | 19 | 105 |
| 2023 September | 76 | 23 | 99 |
| 2023 August | 63 | 20 | 83 |
| 2023 July | 77 | 28 | 105 |
| 2023 June | 61 | 23 | 84 |
| 2023 May | 93 | 23 | 116 |
| 2023 April | 95 | 18 | 113 |
| 2023 March | 67 | 32 | 99 |
| 2023 February | 66 | 31 | 97 |
| 2023 January | 58 | 36 | 94 |
| 2022 December | 62 | 63 | 125 |
| 2022 November | 38 | 27 | 65 |
| 2022 October | 36 | 22 | 58 |
| 2022 September | 32 | 46 | 78 |
| 2022 August | 32 | 29 | 61 |
| 2022 July | 32 | 29 | 61 |
| 2022 June | 27 | 21 | 48 |
| 2022 May | 70 | 36 | 106 |
| 2022 April | 86 | 40 | 126 |
| 2022 March | 62 | 51 | 113 |
| 2022 February | 61 | 21 | 82 |
| 2022 January | 70 | 34 | 104 |
| 2021 December | 35 | 27 | 62 |
| 2021 November | 58 | 45 | 103 |
| 2021 October | 56 | 45 | 101 |
| 2021 September | 67 | 39 | 106 |
| 2021 August | 41 | 48 | 89 |
| 2021 July | 35 | 59 | 94 |
| 2021 June | 56 | 35 | 91 |
| 2021 May | 41 | 28 | 69 |
| 2021 April | 271 | 39 | 310 |
| 2021 March | 114 | 15 | 129 |
| 2021 February | 93 | 32 | 125 |
| 2021 January | 60 | 18 | 78 |
| 2020 December | 52 | 19 | 71 |
| 2020 November | 36 | 18 | 54 |
| 2020 October | 53 | 14 | 67 |
| 2020 September | 54 | 13 | 67 |
| 2020 August | 25 | 18 | 43 |
| 2020 July | 31 | 16 | 47 |
| 2020 June | 39 | 28 | 67 |
| 2020 May | 31 | 20 | 51 |
| 2020 April | 49 | 20 | 69 |
| 2020 March | 32 | 18 | 50 |
| 2020 February | 6 | 3 | 9 |
| 2020 January | 1 | 0 | 1 |
| 2019 December | 4 | 2 | 6 |
| 2019 October | 1 | 0 | 1 |
| 2019 September | 6 | 3 | 9 |
| 2019 July | 0 | 1 | 1 |
| 2019 June | 2 | 4 | 6 |
| 2019 May | 1 | 22 | 23 |
| 2019 April | 0 | 1 | 1 |
| 2019 March | 2 | 5 | 7 |
| 2019 February | 1 | 1 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 6 | 0 | 6 |
| 2018 June | 0 | 1 | 1 |
| 2018 May | 0 | 3 | 3 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 46 | 4 | 50 |
| 2018 January | 57 | 6 | 63 |
| 2017 December | 60 | 8 | 68 |
| 2017 November | 32 | 3 | 35 |
| 2017 October | 36 | 4 | 40 |
| 2017 September | 34 | 5 | 39 |
| 2017 August | 62 | 10 | 72 |
| 2017 July | 43 | 8 | 51 |
| 2017 June | 50 | 13 | 63 |
| 2017 May | 45 | 23 | 68 |
| 2017 April | 31 | 8 | 39 |
| 2017 March | 25 | 8 | 33 |
| 2017 February | 32 | 12 | 44 |
| 2017 January | 18 | 9 | 27 |
| 2016 December | 26 | 13 | 39 |
| 2016 November | 34 | 15 | 49 |
| 2016 October | 31 | 16 | 47 |
| 2016 September | 0 | 7 | 7 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 10 | 1 | 11 |
| 2016 June | 9 | 5 | 14 |
| 2016 May | 12 | 10 | 22 |
| 2016 April | 9 | 1 | 10 |
| 2016 March | 9 | 8 | 17 |
| 2016 February | 6 | 4 | 10 |
| 2016 January | 8 | 1 | 9 |
| 2015 December | 12 | 2 | 14 |
| 2015 November | 11 | 3 | 14 |
| 2015 October | 0 | 2 | 2 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 14 | 6 | 20 |
| 2015 June | 14 | 3 | 17 |
| 2015 May | 17 | 6 | 23 |
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