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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 9 | 14 |
| 2024 Octubre | 88 | 39 | 127 |
| 2024 Septiembre | 97 | 18 | 115 |
| 2024 Agosto | 96 | 69 | 165 |
| 2024 Julio | 102 | 37 | 139 |
| 2024 Junio | 96 | 34 | 130 |
| 2024 Mayo | 78 | 28 | 106 |
| 2024 Abril | 77 | 27 | 104 |
| 2024 Marzo | 94 | 32 | 126 |
| 2024 Febrero | 68 | 28 | 96 |
| 2024 Enero | 68 | 36 | 104 |
| 2023 Diciembre | 99 | 20 | 119 |
| 2023 Noviembre | 91 | 19 | 110 |
| 2023 Octubre | 86 | 19 | 105 |
| 2023 Septiembre | 76 | 23 | 99 |
| 2023 Agosto | 63 | 20 | 83 |
| 2023 Julio | 77 | 28 | 105 |
| 2023 Junio | 61 | 23 | 84 |
| 2023 Mayo | 93 | 23 | 116 |
| 2023 Abril | 95 | 18 | 113 |
| 2023 Marzo | 67 | 32 | 99 |
| 2023 Febrero | 66 | 31 | 97 |
| 2023 Enero | 58 | 36 | 94 |
| 2022 Diciembre | 62 | 63 | 125 |
| 2022 Noviembre | 38 | 27 | 65 |
| 2022 Octubre | 36 | 22 | 58 |
| 2022 Septiembre | 32 | 46 | 78 |
| 2022 Agosto | 32 | 29 | 61 |
| 2022 Julio | 32 | 29 | 61 |
| 2022 Junio | 27 | 21 | 48 |
| 2022 Mayo | 70 | 36 | 106 |
| 2022 Abril | 86 | 40 | 126 |
| 2022 Marzo | 62 | 51 | 113 |
| 2022 Febrero | 61 | 21 | 82 |
| 2022 Enero | 70 | 34 | 104 |
| 2021 Diciembre | 35 | 27 | 62 |
| 2021 Noviembre | 58 | 45 | 103 |
| 2021 Octubre | 56 | 45 | 101 |
| 2021 Septiembre | 67 | 39 | 106 |
| 2021 Agosto | 41 | 48 | 89 |
| 2021 Julio | 35 | 59 | 94 |
| 2021 Junio | 56 | 35 | 91 |
| 2021 Mayo | 41 | 28 | 69 |
| 2021 Abril | 271 | 39 | 310 |
| 2021 Marzo | 114 | 15 | 129 |
| 2021 Febrero | 93 | 32 | 125 |
| 2021 Enero | 60 | 18 | 78 |
| 2020 Diciembre | 52 | 19 | 71 |
| 2020 Noviembre | 36 | 18 | 54 |
| 2020 Octubre | 53 | 14 | 67 |
| 2020 Septiembre | 54 | 13 | 67 |
| 2020 Agosto | 25 | 18 | 43 |
| 2020 Julio | 31 | 16 | 47 |
| 2020 Junio | 39 | 28 | 67 |
| 2020 Mayo | 31 | 20 | 51 |
| 2020 Abril | 49 | 20 | 69 |
| 2020 Marzo | 32 | 18 | 50 |
| 2020 Febrero | 6 | 3 | 9 |
| 2020 Enero | 1 | 0 | 1 |
| 2019 Diciembre | 4 | 2 | 6 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 6 | 3 | 9 |
| 2019 Julio | 0 | 1 | 1 |
| 2019 Junio | 2 | 4 | 6 |
| 2019 Mayo | 1 | 22 | 23 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 2 | 5 | 7 |
| 2019 Febrero | 1 | 1 | 2 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 0 | 3 | 3 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 2 | 1 | 3 |
| 2018 Febrero | 46 | 4 | 50 |
| 2018 Enero | 57 | 6 | 63 |
| 2017 Diciembre | 60 | 8 | 68 |
| 2017 Noviembre | 32 | 3 | 35 |
| 2017 Octubre | 36 | 4 | 40 |
| 2017 Septiembre | 34 | 5 | 39 |
| 2017 Agosto | 62 | 10 | 72 |
| 2017 Julio | 43 | 8 | 51 |
| 2017 Junio | 50 | 13 | 63 |
| 2017 Mayo | 45 | 23 | 68 |
| 2017 Abril | 31 | 8 | 39 |
| 2017 Marzo | 25 | 8 | 33 |
| 2017 Febrero | 32 | 12 | 44 |
| 2017 Enero | 18 | 9 | 27 |
| 2016 Diciembre | 26 | 13 | 39 |
| 2016 Noviembre | 34 | 15 | 49 |
| 2016 Octubre | 31 | 16 | 47 |
| 2016 Septiembre | 0 | 7 | 7 |
| 2016 Agosto | 0 | 1 | 1 |
| 2016 Julio | 10 | 1 | 11 |
| 2016 Junio | 9 | 5 | 14 |
| 2016 Mayo | 12 | 10 | 22 |
| 2016 Abril | 9 | 1 | 10 |
| 2016 Marzo | 9 | 8 | 17 |
| 2016 Febrero | 6 | 4 | 10 |
| 2016 Enero | 8 | 1 | 9 |
| 2015 Diciembre | 12 | 2 | 14 |
| 2015 Noviembre | 11 | 3 | 14 |
| 2015 Octubre | 0 | 2 | 2 |
| 2015 Septiembre | 0 | 1 | 1 |
| 2015 Agosto | 0 | 2 | 2 |
| 2015 Julio | 14 | 6 | 20 |
| 2015 Junio | 14 | 3 | 17 |
| 2015 Mayo | 17 | 6 | 23 |
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