Advertise With UsA necklace-like pattern pointed to
malnutrition and anorexia nervosa.
Reprinted from Eating Disorders Review
November/December 2011 Volume 22, Number 6
©2011 Gürze Books
After only about 10 minutes of exposure to the sun, a 38-year-old woman noticed erythema with a burning sensation on her hands and calves. An 18-year-old woman was alarmed at erythema on her face and neck after only a few hours of exposure to the sun. In both cases, the women were found to have anorexia nervosa (AN) (J Dermatol 2011; 38:1037).
According to her husband, the 38-year-old woman had been rigidly dieting and using laxatives. When she was seen for the sunburn, she had a body mass index (BMI) of only 10.8 kg/m2. Acute liver damage was suspected. She refused hospitalization and psychiatric consultation. She died shortly afterward and an autopsy pointed to malnutrition. The 18-year-old was also severely malnourished, and had lost 12 kg of weight over the previous month. She was treated with a topical steroid, and returned the next summer with the same pattern of sunburn. When she was seen again, her BMI was 14.2 kg/m2. At follow-up, she was being treated and was struggling to regain weight.
In both women, the unusual skin eruptions were related to malnutrition-related pellagra, which is characterized by sunburn-like erythema with blistering, hyperpigmentation, and peeling in exposed areas. The clinical presentation in such cases will show a variety of abnormalities, including a classic “necklace-like” pattern of sunburn. In these two cases, erythema followed the clavicles and resembled a necklace-different from the usual pattern of sunburn that covers the entire chest. Pellagra-related skin changes or “sunburn” of this nature is considered to be due to phototoxicity. Although the mechanism is not fully understood, according to the authors, it may result from a deficiency of urocanic acid, which absorbs ultraviolet light.
Dr. Mami Sato and colleagues note that sunburn-like skin changes such as these may compel malnourished patients who do not know they have AN to seek treatment. For general physicians, pellagra-like dermatitis in a very thin patient may be a serious sign, and psychiatric consultation is warranted.