Acquired Acrodermatitis Enteropathica
A 54-year-old woman presented with a 4-month history of intractable rash that was not responsive to topical glucocorticoid and antifungal treatment. She had undergone bariatric surgery with Roux-en-Y gastric bypass about 8 years previously. She reported that during the preceding few months, she had stopped taking her multivitamins and had not been eating much because of a lack of appetite and financial difficulties. On examination, an erythematous, desquamating rash associated with excoriations and honey-colored crusting was noted. The rash was predominant over the lumbosacral region (Panel A), the perioral region (Panel B), and the inguinal region, as well as on her forearms and hands in association with palmar erythema and fissuring. Skin biopsy revealed nonspecific histologic findings of parakeratosis, impetiginized regions, and chronic inflammation with dermal edema. A workup for infectious and autoimmune conditions was not revealing. An evaluation for micronutrient deficiencies caused by malabsorptive bariatric surgery and poor nutritional intake revealed a plasma zinc level of 0.31 μg per milliliter (4.7 μmol per liter) (normal range, 0.55 to 1.50 μg per milliliter [8.4 to 23.0 μmol per liter]). Acquired acrodermatitis was diagnosed, and the patient began a regimen of zinc supplementation. Nearly complete resolution of the rash was noted at follow-up 4 weeks later.