AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Acrodermatitis enteropathica (AE) is a rare autosomal recessive disorder characterized by periorificial and acral dermatitis, alopecia, growth failure, gastrointestinal disturbance, and diarrhea. Symptoms of AE occur within the first few months after birth and tend to appear in nonbreastfed infants or in infants shortly after discontinuation of breastfeeding. Ocular complications include lid and surface involvement as well as secondary infections.

Pathophysiology

The nature of the metabolic defect is currently attributed to zinc absorption. The AE mutation creates reduced zinc uptake and abnormal zinc metabolism in human fibroblasts. The gene defect is located on chromosome 8, characterized as the intestinal zinc transporter gene, or SLC39A4 gene, at locus 8q24.3.

Frequency

United States

Unknown

International

It is estimated that 1 in 500,000 people in Denmark are affected.

Mortality/Morbidity

AE is lethal, usually within the first few years of life, if left untreated. However, an untreated adult survivor was reported.

Race

No racial predilection exists.

Sex

No sexual preference exists.

Age

AE appears in the first few months after birth or after cessation of breastfeeding.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Symptoms of AE occur within the first few months after birth in nonbreastfed infants or tend to appear in infants shortly after discontinuation of breastfeeding.
• Ocular disease is a byproduct of lid, conjunctival, and ocular surface deficits.
• Infants display photophobia and blepharospasm, which may threaten deprivation amblyopia in severe cases.
• Lid sloughing and secondary infections can be significant. Alopecia of the scalp, eyebrows, and cilia is common.
• Chronic conjunctivitis, blepharitis, punctate keratopathy, and even keratomalacia further complicate the ocular picture.

Physical

• Physical examination is significant for erythematous patches and plaques of dry, scaly, eczematous skin, which may evolve into crusted, vesiculobullous, erosive, and pustular lesions. Lesions are distributed in a periorificial and acral pattern, on the face, scalp, lids, hands, feet, and anogenital areas.
• Paronychia and alopecia with loss of scalp hair, eyebrows, and eyelashes may occur.
• Ocular manifestations may also include punctal stenosis, corneal changes, and keratomalacia.
• The cutaneous lesions may become secondarily infected with Staphylococcus aureus and Candida albicans.
• Infants also may experience withdrawal, growth failure, photophobia, and loss of appetite, leading to failure to thrive.

Causes

The appearance of AE shortly after the cessation of breastfeeding has led many to believe that human milk has a beneficial ligand, which bovine milk lacks. Evans and Johnson postulated picolinate as the ligand; Lonnerdal suggested citric acid; Cousins and Smith proposed that the protein concentration of human milk affects zinc bioavailability.

The nature of the metabolic defect has been debated and clarified with the identification of the 8q24.3 locus. Fibroblast proteins that are absent in the fibroblasts of patients with AE have recently been discovered, suggesting that these proteins may be responsible for decreased zinc uptake and abnormal zinc metabolism.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Acquired zinc deficiency
Alopecia
Atopic dermatitis
Biotin and multiple decarboxylase deficiencies
Candidiasis (cutaneous)
Candidiasis (mucosal)
Cystic fibrosis
Essential fatty acid deficiencies
Epidermolysis bullosa
Glucagonoma syndrome
Histiocytosis X
Kwashiorkor
Seborrheic dermatitis
Glutaric aciduria type 1
Leucinosis
Nonketotic hyperglycinemia
Food allergy

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Plasma zinc levels are low and characteristic histopathologic findings are seen on skin biopsy.
• Hair, urine, and parotid saliva zinc levels, as well as serum alkaline phosphatase activity (which lowers later in the disease) may be helpful.
• Maternal breast milk zinc concentrations also may help differentiate AE from acquired zinc deficiency.

Other Tests

• The gene for AE is localized to chromosomal region 8q24.3 and the SLC39A4 gene, thereby identified as the gene for AE. SLC39A4 mutations have been demonstrated in several families with AE, and, in the initial Nakano study, 2 Japanese families with AE and with SLC39A4 mutations were described. Their mutation detection strategy consisted of polymerase chain reaction amplification of all 12 exons and flanking intronic sequences, followed by direct nucleotide sequencing. It revealed 3 novel mutations, 1017ins53, which creates a premature termination codon, and 2 mis-sense mutations, R95C and Q303H. These techniques can be used to identify carriers, newborns, or fetuses by amniocentesis.

Histologic Findings

Histopathologic examination of the skin and eyelids reveals parakeratosis of the stratum corneum with occasional neutrophils and intracellular edema. The granular cell layer is diminished, and the upper epidermis demonstrates pallor and edema. Focal dyskeratosis is seen. The epidermis may be psoriasiform or atrophic. Occasionally, subcorneal (cutaneous) pustules are seen.

One case report details the ocular histopathology of a child who died before efficacious treatment was available. The findings include corneal epithelial thinning and loss of polarity of corneal epithelial cells, anterior corneal scarring and loss of Bowman membrane, cataract formation, ciliary body atrophy, retinal degeneration, retinal pigment epithelium (RPE) depigmentation, and optic atrophy.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Systemic treatment requires lifelong zinc supplementation. Ocular therapy requires vigorous ocular surface supportive measures and intervention when secondary bacterial or candidal infection, trichiasis, or other complications occur. There is no known corrective genetic treatment available. Good copies of the defective gene have not yet been coupled to vectors capable of altering human phenotypes.

Surgical Care

Advanced cases may require oculoplastic surgical intervention including lid reconstruction, tarsorrhaphy, or epilation therapy. Ocular surface reconstruction with conjunctival transplantation or human amniotic membrane grafts also is a possibility in severe situations. Corneal transplantation may be required in cases of severe keratomalacia or infectious keratitis. These therapies are recommended with good judgment in the context of severe failure to thrive and limited predicted life span.

Consultations

Consultation with pediatrics, genetics, dermatology, or plastic surgery may be useful.

Diet

Treatment of patients with AE involves greater than 1-2 mg/kg of oral zinc supplementation per day for life. No special diet is necessary as long as zinc supplementation is continued.

Activity

No activity limitations are required in adequately treated cases. Patients with severe ocular surface inflammation may require certain restrictions from dusty, dry, or dirty environments.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Treatment of patients with AE involves greater than 1-2 mg/kg of oral zinc supplementation per day for life.

Drug Category: Mineral supplements

These agents are used to reduce morbidity and to prevent complications.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Severely ill infants are admitted until stable. If untreated, cutaneous and lid lesions may become secondarily infected with S aureus and C albicans. Infants also may experience withdrawal, photophobia, and loss of appetite.
• Further progression and even death from secondary infection may occur if AE is left untreated.

Further Outpatient Care

• Zinc supplementation as already described
• Periodic ophthalmologic follow-up care as indicated
• Periodic dermatologic follow-up care as indicated

In/Out Patient Meds

• Zinc supplementation as previously described
• Topical ophthalmologic preparations for irritative or infectious complications as indicated
• Topical dermatologic preparations for irritative or infectious complications as indicated
• Systemic antibiotics for severe ocular or cutaneous infectious complications as indicated

Deterrence/Prevention

• Genetic counseling may be important to parents inquiring about conceiving additional children. Additional family members at risk also may be discovered.

Complications

• Ophthalmologic irritative complications and secondary infections, particularly with Staphylococcus and C albicans
• Lid disease including seborrheic and infectious blepharitis, trichiasis, and entropion
• Severe corneal disease including ectasia, infectious keratitis, and keratomalacia
• Secondary Sjögren syndrome and keratitis sicca
• Dermatologic irritative states and secondary infections, particularly with Staphylococcus and C albicans

Prognosis

• With early diagnosis and zinc supplementation, the prognosis is good. Ophthalmic complications are far less severe when the systemic disease is treated. Advanced cases may have severe ophthalmic complications.
• Ocular surface complications and infections
• • Blepharitis
  • Conjunctivitis
  • Keratitis, corneal ectasia, keratomalacia, and corneal neovascularization
• Eyelid complications
• • Trichiasis and entropion with secondary corneal damage
  • Ectropion, ptosis, lash loss, brow loss, and other lid deformities
  • Symblepharon
• Amblyopia

Patient Education

• Dietary and genetic counseling are important.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Early diagnosis and treatment should preclude any medical/legal pitfalls. Follow-up care with the appropriate specialists, and clear instructions for zinc supplementation are essential. Delayed diagnosis presents the most urgent cause for litigation risk, which usually lies within the realm of the pediatrician.

Special Concerns

• AE can be diagnosed by the astute pediatrician familiar with its presentation. Dermatologic consultation may be key, while the ophthalmologist rarely is called upon to finalize the diagnosis. AE may only be diagnosed accurately through dietary zinc restriction and withdrawal, since a genetically based test currently is unavailable. Patients with AE must remain on zinc supplementation for life. Differentiating AE from acquired zinc deficiencies can be difficult since both present in the same manner. Low zinc levels in the mother's milk may produce an acquired zinc deficiency in full-term, breastfed infants.
• Zimmerman et al have proposed that some acquired zinc deficiencies may be caused by a defect in mammary zinc secretion. Their studies may dispute the claim that human breast milk has a protective effect against zinc deficiency. Acquired zinc deficiency also occurs in premature infants, whether maternal zinc levels are low or normal, due to the infants' greater bodily demand and immaturely developed bodily zinc storage.
• Infections are an important finding in AE. Zinc deficiency diminishes antibody- and cell-mediated responses in both humans and animals. The moderate deficiencies in zinc noted in sickle cell anemia, renal disease, chronic gastrointestinal disorders, and AE cause variable degrees of morbidity and mortality secondary to infection.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Aggett PJ, Atherton DJ, More J, et al. Symptomatic zinc deficiency in a breast-fed preterm infant. Arch Dis Child. Jul 1980;55(7):547-50. [Medline].
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• Bye AM, Goodfellow A, Atherton DJ. Transient zinc deficiency in a full-term breast-fed infant of normal birth weight. Pediatr Dermatol. Jul 1985;2(4):308-11. [Medline].
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• Champion RH, et al, eds. Rook/Wilkinson/Ebling Textbook of Dermatology. Vol. 3. 1998: 2668.
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• Evans GW, Johnson PE. Characterization and quantitation of a zinc-binding ligand in human milk. Pediatr Res. Jul 1980;14(7):876-80. [Medline].
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• Glover MT, Atherton DJ. Transient zinc deficiency in two full-term breast-fed siblings associated with low maternal breast milk zinc concentration. Pediatr Dermatol. Feb 1988;5(1):10-3. [Medline].
• Graves K, Kestenbaum T, Kalivas J. Hereditary acrodermatitis enteropathica in an adult. Arch Dermatol. May 1980;116(5):562-4. [Medline].
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• Nakano A, Nakano H, Nomura K. Novel SLC39A4 mutations in acrodermatitis enteropathica. J Invest Dermatol. 2003;Jun;120(6):963-6. [Medline]. [Full Text].
• Ozturkcan S, Icagasioglu D, Akyol M, Cevit O. A case of acrodermatitis enteropathica. J Dermatol. Jul 2000;27(7):475-7. [Medline].
• Roberts LJ, Shadwick CF, Bergstresser PR. Zinc deficiency in two full-term breast-fed infants. J Am Acad Dermatol. Feb 1987;16(2 Pt 1):301-4. [Medline].
• Schacner LA, Hansen RC. Pediatric Dermatology. New York, New York: Churchill Livingstone;1988:759.
• Schmidt CP, Tunnessen W. Cystic fibrosis presenting with periorificial dermatitis. J Am Acad Dermatol. Nov 1991;25(5 Pt 2):896-7. [Medline].
• Van Wouwe JP. Clinical and laboratory diagnosis of acrodermatitis enteropathica. Eur J Pediatr. Oct 1989;149(1):2-8. [Medline].
• Vasantha K, Kannan KA. Acrodermatitis enteropathica--a case report. Indian J Ophthalmol. Oct-Dec 1989;37(4):197-8. [Medline].
• Zimmerman AW, Hambidge KM, Lepow ML, et al. Acrodermatitis in breast-fed premature infants: evidence for a defect of mammary zinc secretion. Pediatrics. Feb 1982;69(2):176-83. [Medline].

Article Last Updated: Sep 21, 2006