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ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 108-111

Phyrnoderma: Associated nutritional co-morbodities among children attending at Nutrition Clinic, Osmania General Hospital, Hyderabad, India


Clinical Division, National Institute of Nutrition, ICMR, Jamai Osmania, Hyderabad, India

Date of Web Publication30-Mar-2016

Correspondence Address:
Amruth Rao Parveda
Scientist-D, Food and Drug Toxicology Research Center, National Institute of Nutrition (NIN), ICMR, Jamai Osmania, Hyderabad - 500 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.175657

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  Abstract 

Introduction: Phrynoderma, meaning toad skin, is a form of follicular hyperkeratosis. Multiple nutritional deficiency disorders have been implicated in the etiology of phrynoderma. It is commonly seen in the children belonging to low socio-economic strata, clinically characterized by discrete, follicular, skin colored papules with keratotic plugs distributed over elbows, knees, extensor extremities and buttocks. The present study aims to determine the clinical presentation and associated nutritional co morbidities in diagnosed phrynoderma cases.
Materials and Methods: A series of 339 clinically diagnosed phyronderma cases attending the Nutrition Unit of tertiary care hospital during a period from September 1995 to March 2014 were retrospectively reviewed. All cases were reviewed for clinical history, cutaneous examination findings including associated signs of nutritional deficiencies.
Results: In a total of 339 patients of Phrynoderma studied, there were 195 males and 144 females. Majority of patients were in 6-10years age group. The lesions were distributed bilaterally and symmetrically in 196 (57.8%) patients. The lesions were localized predominantly to elbow followed by extremities in upper body and knees in lower body followed by buttocks. A total of 16.2% patients had associated ocular and skin findings and 13.3% of patients had the signs of Vitamin A deficiency.
Conclusion: Phyrnoderma is a disorder of young children and adolescents and can be considered as multifactorial disease involving deficiencies of various nutrients along with local factors such as pressure and friction responsible for pathogenesis of the disease.

Keywords: Follicular papules, keratotic plugs, phrynoderma


How to cite this article:
Parveda AR, Upputuri B, Hemalatha R. Phyrnoderma: Associated nutritional co-morbodities among children attending at Nutrition Clinic, Osmania General Hospital, Hyderabad, India. Indian J Paediatr Dermatol 2016;17:108-11

How to cite this URL:
Parveda AR, Upputuri B, Hemalatha R. Phyrnoderma: Associated nutritional co-morbodities among children attending at Nutrition Clinic, Osmania General Hospital, Hyderabad, India. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Nov 14];17:108-11. Available from: http://www.ijpd.in/text.asp?2016/17/2/108/175657


  Introduction Top


Phrynoderma is a form of follicular hyperkeratosis seen in young children and adolescents due to nutritional deficiencies. It is clinically characterized by discrete, follicular, skin-colored papules with keratotic plugs distributed over elbows, knees, extensor extremities, and buttocks.[1] Nicholls in 1933 coined the term phrynoderma, meaning “toad skin” and described as hyperkeratotic follicular papules in East African laborers for the first time and thought to be deficient in Vitamin A.[2]

Various nutritional deficiencies such as Vitamin A, Vitamin B complex, Vitamin C, Vitamin E and essential fatty acid (EFA) including protein energy malnutrition have been considered as possible etiological factors. However, exact etiology of phrynoderma is yet to be established, and hence there is no single specific therapy available for the disease.[3] Recent study from South India had showed that the intramuscular injection of Vitamin A/Vitamin B complex are effective in the treatment of phrynoderma.[4]

In India, it is commonly seen in low socioeconomic group of population. Although rare in developed countries, it still exists among poor population and is seen among patients with malabsorption from various etiologies and also in hospitalized patients.[5] Therefore, it should be considered in the differential diagnosis in patients with hyperkeratotic folliculitis in clinical settings of malnutrition.[6] Phrynoderma is believed to be manifestation of nutrition deficiency and it has been included as a sign to be looked for in the schedule for the assessment of nutritional status of individuals.[7] The present study aims to elucidate a series of 339 cases and includes their clinical findings and associated nutritional comorbidities.


  Materials and Methods Top


The case records of 339 consecutive patients with clinical diagnosis of phrynoderma attending the Nutrition Unit of Osmania General Hospital, Hyderabad during a period from September 1995 to March 2014 were retrospectively reviewed [Figure 1]. The clinical histories are reviewed for age, sex, seasonal variation, including cutaneous examination findings such as distribution, sites of involvement, associated skin findings, and eye symptoms. The disease is clinically diagnosed if the patient present with discrete, follicular papules with conical keratotic plugs on extensor surfaces of extremities. The lesions may also distribute over back, buttocks, and any part of the body. All the data were tabulated and grouped into five groups based on the age.
Figure 1: Year-wise distribution of phrynoderma cases

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  Results Top


Among 339 patients attending the nutrition OPD, 195 were males and 144 were females. In the [Table 1], the age of the patients ranged from 3 to 25 years with a mean age 9.36 ± 3.22 in males and 9.58 ± 3.97 in females with majority of the patients in the age group of 6–10 years (55.2%). About 24.9% of the patients presented during summer, 38.8% in winter season, and 36.2% in rainy season. In the [Table 2], the distribution of lesions was bilateral and symmetrical in 196 (57.8%) patients. The distributions of lesions were categorized into upper and lower body lesions. In upper body, lesions were predominantly seen over elbow followed by extremities and knees in lower body followed by buttocks. In the [Table 3], associated skin conditions and other nutrition deficiency features were noted.
Table 1: Age.wise distribution of phrynoderma cases

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Table 2: Sites of involvement in phrynoderma

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Table 3: Associated conditions/disorders in phrynoderma

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  Discussion Top


Phrynoderma is a disease commonly seen in the age group between 5 and 15 years. However, the disease is uncommon in the children < 5 years of age (<5%).[8],[9] In the present study, the disease was also noted in the children in the age group of < 5 years (9.4%) [Table 1]. Males were predominately involved than females which is comparable with previous studies.[8],[9] Though, there are other studies indicating equal incidence in both the genders [10],[11],[12] preponderance were indicating that the phrynoderma does not show any difference between sexes in their development. Most of the patients in the present study were asymptomatic and few complained of itching which are similar to previous studies.[8] According to previous study, the incidence of the disease is higher in cooler months of the year as we reported in the present study.[3]

The majority of the lesions were symmetrically distributed on bony prominences where friction is common which was in accordance with observation made by several investigators according to whom distribution of lesions is always symmetrical and either localized or generalized.[8] Skin lesions are characterized by follicular papules with keratotic plugs on the extensor surfaces of the extremities. Elbow and knees being the most common area involved, but lesions may also involve the abdomen, back, and buttocks, typically sparing the hands, feet, and face.[13] In the present study, elbow (76.4%) is the most common area of involvement followed by knee (49.3%), buttocks (28.3%), and extensor extremities (10%) which was comparable with other studies.[8],[10] We report 3.5% of patients with facial involvement [Table 2].

In the [Table 3], a total of 16.2% patients have associated skin and ocular findings. Among them, Vitamin A deficiency disorders were predominately found in 13.3% of the patients, which are higher when compared with previous studies (5%).[10] In the present study, 1.5% of the patients had B complex group of vitamin deficiencies which is very much less when compared with previous studies (92%,[11] 65%,[8] and 47.6%[14]). As most of the studies on phrynoderma conducted on middle of last century, the authors have observed high prevalence of Vitamin B deficiency disorders in phrynoderma patients. The decrease in the prevalence may be attributed to improvement in nutritional status and due to implementation of various nutritional programs.[3] None of the patients in the present study showed nutritional deficient signs of Vitamin C, E and EFA. The combination therapy with Vitamin A and B along with EFA (Safflower oil) supplementation showed the better results when compared with Vitamin A or B monotherapy.

The main limitation of our study is lack of histopathological examination of skin lesions and biochemical analysis of nutrients in the patients. Since Safflower oil is the richest source of EFA might be reason for good response to the treatment and cannot be concluded due to lack of biochemical evidence. Thus, a multi-factorial disorder involving multiple nutrients and local factors such as pressure and friction also plays a major role in the development of phrynoderma.


  Conclusion Top


Phrynoderma is a disorder of young children and adolescents involving multiple deficiencies of nutrients along with local factors such as friction and pressure. Since, phrynoderma is multifactorial disease combination therapy with vitamins and EFA along with adequate nutrition. Further, prospective case control studies are required to delineate the exact pathogenesis and the role of different nutrients in the development of phrynoderma.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Nakjang Y, Yuttanavivat T. Phrynoderma: A review of 105 cases. J Dermatol 1988;15:531-4.  Back to cited text no. 1
[PUBMED]    
2.
Nicholls L. Phrynoderma: A condition due to vitamin deficiency. Indian Med Gaz 1933;68:681-7.  Back to cited text no. 2
    
3.
Ragunatha S, Kumar VJ, Murugesh SB. A clinical study of 125 patients with phrynoderma. Indian J Dermatol 2011;56:389-92.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Ragunatha R, Kumar VJ, Murugesh SB, Ramesh M, Narendra G, Kapoor M. Therapeutic response of Vitamin A, Vitamin B complex, essential fatty acids (EFA) and Vitamin E in the treatment of phrynoderma: A randomized controlled study. J Clin Diagn Res 2014;8:116-8.  Back to cited text no. 4
    
5.
Barr DJ, Riley RJ, Greco DJ. Bypass phrynoderma. Vitamin A deficiency associated with bowel-bypass surgery. Arch Dermatol 1984;120:919-21.  Back to cited text no. 5
[PUBMED]    
6.
Chia MW, Tay YK, Liu TT. Phrynoderma: A forgotten entity in a developed country. Singapore Med J 2008;49:e160-2.  Back to cited text no. 6
    
7.
Maronn M, Allen DM, Esterly NB. Phrynoderma: A manifestation of Vitamin A deficiency? The rest of the story. Pediatr Dermatol 2005;22:60-3.  Back to cited text no. 7
    
8.
Ayyangar MC. Phrynoderma and nutritional deficiency. Indian J Dermatol Venereol Leprol 1967;33:13-24.  Back to cited text no. 8
    
9.
Rajagopal K, Chowdhury SR. Phrynoderma and some associated changes in blood lipids. Indian Med Gaz 1952;87:350-3.  Back to cited text no. 9
    
10.
Panja SK, Chatterjee SK, Mukherjee KL. Follicular keratosis in children. Indian J Dermatol 1970;15:75-8.  Back to cited text no. 10
    
11.
Gopalan C. The aetiology of phrynoderma. Indian Med Gaz 1947;82:16-20.  Back to cited text no. 11
    
12.
Shrank AB. Phrynoderma. Br Med J 1966;1:29-30.  Back to cited text no. 12
    
13.
Kelly P. Folliculitis and the follicullar occlusion tetrad. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. New York: Mosby; 2003. p. 553-66.  Back to cited text no. 13
    
14.
Srikantia SG, Belavady B. Clinical and biochemical observation a in phrynoderma. Indian J Med Res 1961;49:109-14.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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