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AUTHOR AND EDITOR INFORMATION

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Author: Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Robert A Schwartz is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Coauthor(s): Jack Grzybowski, MD, Staff Physician, Department of Pediatrics, UMDNJ-New Jersey Medical School

Editors: Maureen B Poh-Fitzpatrick, MD, Professor Emerita of Dermatology and Special Lecturer, Columbia University; Professor of Medicine (Dermatology), University of Tennessee; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Mary Farley, MD, Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: excessive intake of carrots, ingestion of carotene, beta carotene, beta-carotene

INTRODUCTION

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Background

Carotenemia is a common finding in children, mainly due to the excessive intake of carrots, but it can also be associated with the ingestion of many other yellow and green vegetables and citrus fruits. Carotene is a lipochrome that normally adds yellow color to the skin. With elevated blood levels of carotene, the prominence of this yellowing is increased. Carotenemia may be particularly evident when the stratum corneum is thickened or when the subcutaneous fat is strongly represented. The condition of carotenemia is harmless, but it can lead to a mistaken diagnosis of jaundice.

Awareness of carotenemia may avoid confusion with jaundice and unnecessary diagnostic studies. Mothers may induce it by giving their infants large amounts of carrots in commercial infant food preparations.1 Hypothyroidism,2 diabetes mellitus,3 hepatic diseases, anorexia nervosa, and renal diseases may be associated with carotenemia unassociated with the ingestion of carotene.4 Carotenemia may also be associated with the ingestion of carotene-rich nutritional supplements.5

Red hues are a challenge for animal coloration, as multiple pigments such as carotenoids, pheomelanin, psittacofulvins, porphyrins, turacin, and hemoglobin may confer red colors.6

eMedicine's Pediatric article Carotenemia may be of interest, as may the Medscape Nutrition Resource Center.

Pathophysiology

Excessive intake of vitamin A precursors in foods, principally carrots, can lead to a yellow discoloration of the skin but not of the sclera and oral cavity. This condition most commonly occurs in children with liver disease, hypothyroidism, or diabetes mellitus. The absorption of dietary carotenoid requires dietary fat and is enhanced by administering with meals. The conversion of beta-carotene (provitamin A) to vitamin A is accelerated by thyroxine and hyperthyroidism. Excessive ingestion of carotenoids is nontoxic and does not cause hypervitaminosis A because the conversion of carotene to vitamin A is slow.

Frequency

International

This disorder most commonly occurs in vegetarians and young children.

Mortality/Morbidity

Carotenemia is a benign condition.

Race

Carotenemia is more easily appreciated in light-complexioned people, and it may present chiefly as yellowing of the palms and the soles in more darkly pigmented persons.

Age

Carotenemia may occur at any age, but it is most common in children.


CLINICAL

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History

  • A history of excessive carotene intake consistent with the diagnosis of hypercarotenemia is usually present. Carotenemia can be verified by a high serum beta-carotene level, a normal or slightly elevated vitamin A level, and normal liver function test results. Accumulation of beta-carotene in the skin is delayed by up to 2 weeks compared to the serum. Because of the lipophilic nature of carotenoids, sufficient amounts can remain in tissue for several months, causing yellow skin even after serum carotene levels return to normal.
  • Metabolic carotenemia without a history of excessive carotene intake may be due to a genetic defect in the metabolism of carotenoids.
  • Amenorrhea may be associated with carotenemia. This occurs in patients who consume a pure or predominantly vegetarian diet without red meat. Dietary modifications can reduce carotene levels, which, in turn, normalize the menstrual cycle.
  • A correlation between metabolic carotenemia and biliary dyskinesia has been suggested. In patients with metabolic carotenemia, significant relationships were identified between the gall bladder contraction rate and the levels of serum carotene, vitamin A, and lipids.
  • Carotenemia may be due to the ingestion of red palm oil. Because of the lipophilic nature of carotenoids, sufficient amounts may remain in the skin to produce discoloration for up to 5 months, even if serum beta-carotene levels have returned to normal.

 

Physical

  • Yellow skin discoloration, especially on the palms and the soles, without affecting the sclera, is present.
    • Yellowish pigmentation of the skin (xanthoderma) may be caused by many conditions.
    • Ascertaining the presence or the absence of scleral icterus is important in determining the diagnosis.
    • Yellow sclerae are found in patients with all etiologies of elevated serum bilirubin because scleral tissues are rich in elastin, which has a special affinity for bilirubin.
  • The liver and the spleen are not enlarged.

Causes

  • Excessive intake of carotenoid-rich vegetables (mainly green and yellow) and fruits7 causes carotenemia.


DIFFERENTIALS

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Other Problems to be Considered

Jaundice
Lycopenemia (orange-yellow skin discoloration due to the ingestion of large amounts of tomatoes)
Riboflavinemia
Yellow skin discoloration associated with use of the oral multitargeted tyrosine kinase inhibitor sorafenib for treatment of metastatic renal cell carcinoma8


WORKUP

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Lab Studies

  • The serum beta-carotene level can be increased 3-4 times the normal value and still be associated with a normal or only slightly elevated vitamin A level.
  • Liver function test results rarely become abnormal.

Histologic Findings

A skin biopsy specimen may show autofluorescence in the superficial horny layer and a pemphiguslike pattern of intracellular autofluorescence.


TREATMENT

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Medical Care

Carotenemia is a benign condition that improves with dietary modification.

Diet

Recommend a diet without excessive carotene.


FOLLOW-UP

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Complications

  • Complications usually do not occur.

Prognosis

  • A low carotene diet leads to progressive disappearance of the yellow skin discoloration.
  • Yellow skin color may remain for up to a few months regardless of the serum carotene level because of accumulation in the tissue.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • The incorrect diagnosis of jaundice may produce medicolegal problems because carotenemia can be confused with jaundice.


REFERENCES

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Carotenemia excerpt

Article Last Updated: May 13, 2008