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Functional Nutrition Evaluation CLINICAL INDICATORS: SKIN EXAM Companion Guide Version 2 nsight.org

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Page 1: Functional Nutrition Evaluation CLINICAL INDICATORS: SKIN …...Flaking, scaly dermatitis n EFA, zinc, vitamin A, riboflavin, biotin n Excess vitamin A Malabsorption syndromes Flaky

Functional Nutrition Evaluation CLINICAL INDICATORS:

SKIN EXAMCompanion Guide

Version 2

nsight.org

Page 2: Functional Nutrition Evaluation CLINICAL INDICATORS: SKIN …...Flaking, scaly dermatitis n EFA, zinc, vitamin A, riboflavin, biotin n Excess vitamin A Malabsorption syndromes Flaky

Table of Contents

The Skin Exam from the Functional Medicine Perspective .................................... 3

Positioning ...................................... 3

The Examination ............................. 3

Points of Connection ...................... 9

Further Clinical Evaluation ........... 13

Functional Medicine Matrix ......... 14

Conclusion ................................... 14

Acknowledgements ..................... 15

Skin Exam References .................. 15

© 2016 The Institute for Functional Medicine

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 3© 2016 The Institute for Functional Medicine

“The skin is the largest organ in the body and the health of your body and your nutrition status is often reflected in your skin.” —Elizabeth Boham, MD, MS, RD

The Skin Exam from the Functional Medicine PerspectiveThe skin has its own unique endocrine and immune system and is the organ most distal to the heart. An adult skin weighs 5 to 6 kg, is over 2 square meters in area, has 5 million hair follicles, with 75% of its weight and 90% of its protein being collagen.1 Its nutritional requirements are somewhat unique because of the rapid turnover and replacement of its protective layers.

Patients with changes in their skin have imbalances due to decreased intake or absorption, increased requirement, altered utilization, or imbalanced intake of other nutrients. Functionally these requirements are determined by assimilation, immune balance, energy and mitochondrial requirements, detoxification or biotransformation (phase I or II), transport, communication, or structure.

Equipment for the Skin Exam

n Gloves (latex free)n Magnifier, episcopen Cameran Glass slidesn Potassium hydroxide 10-20% solution2

n Normal saline solutionn Paper or cloth drapesn Ruler or measuring tooln Blood pressure cuff/stethoscope (for Hess test)

PositioningThe patient should feel comfortable. They should sit on the exam table with the space and ability to lie supine or prone, or stand so the clinician has easy access for the examination. The patient will both sit and lie down during the exam. Use versatile draping to cover the sensitive areas yet allow easy visualization of skin surfaces.

There are six general skin characteristics that change with functional nutritional status: temperature, texture and thickness, color, hydration, hair distribution, and associated lesions.

The ExaminationAn examination from the tip of the hair to the ends of the toes can reveal significant nutrient-associated findings. These are summarized in Table 1. First, with palpation the temperature, texture, and thickness of the skin is appreciated. These observations begin the sorting of possible diet and nutrient associations. Second, the clinician observes the color and hydration of the skin. Next, hair distribution is noted; hair distribution can be markedly altered by nutritional status. Finally, each lesion should be evaluated, magnified, measured, and documented (with photograph or description) as appropriate.

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 4© 2016 The Institute for Functional Medicine

Sign

Nutrition-Associated Deficiency or Consideration

Nutrition-Related Conditions and Other Associations (partial listing)

Temperature

< 36° C n Iodinen Severe water loss (dehydration)

Hypothyroidism

> 38° C n Coppern Severe dehydration

Infection, increased basal metabolic rate(BMR), recent surgery, hyperthyroidism

Texture

Casal’s necklace—symmetrical darkening around neck, scaly dermatitis

Niacin Pellagra, liver disease, esophageal cancer12

Dermatitis (generalized) Essential fatty acids (EFA),13 zinc14 Atopic disease, contact allergic or medication rash, psoriasis

Dermatitis herpetiformis—small pruritic blisters on shoulders, elbows, knees, lumbosacral area

Zinc, magnesium, iron, selenium, niacin, folate*, B12 (associated with gluten enteropathy in dermatitis herpetiformis patients)15

Gluten-sensitive enteropathy, linear IgA bullous disease, autoimmune systemic disease, malignant neoplasms, HLA DR3 (95%), HLADQw2 (100%)16

Dermatitis—periorificial, acrodermatitis

Zinc,14,17-19 biotin, EFA, protein Atopic dermatitis, acrodermatitis enteropathica, candidiasis, epidermolysis bullosa

Dyssebacia (shark skin)— greasy, grey, yellow filiform outgrowths from retained sebum in sebaceous glands

B complex Alcoholism, liver disease

Eczema—atopic dermatitis n Vitamins A, D,20,21 E, EFA,13,22 zincn Consider other cofactor adequacy

of elongases and desaturases and nutrients of immune balance.23-30

IgE-responsive environmental/food (eggs, peanuts, milk, fish, soy, or wheat) allergies, Trichophyton or other secondary infections (staph), emotional stress, low humidity, irritants (hygiene or makeup components), overwashing

Flaking, scaly dermatitis n EFA, zinc, vitamin A, riboflavin, biotinn Excess vitamin A

Malabsorption syndromes

Flaky paint (crazy paving dermatosis)—tendency to desquamate leaving hyperpigmented skin and superficial ulcerations

Protein, vitamin A Kwashiorkor, Whipple’s disease

Follicular hyperkeratosis (toad skin)—papules at the tips of hair follicles, posterior or lateral arms, extensor surfaces of limbs

EFA, vitamin A (phrynoderma), B vitamins, zinc25,26,31-33

Whipple’s disease, celiac disease

Nasolabial seborrheic dermatitis—around the nares and can extend to upper lip and corners of the mouth

Riboflavin, niacin, B6 Pellagra, renal failure, liver disease, alcoholism, hyperthyroidism

Perifolliculitis Vitamin C Scurvy, alcoholism

Psoriasis34-47 Nickel, bromine, zinc, vitamin A Imbalance in cAMP, cGMP; NSAID and acetaminophen use,34 decreased physical activity,35 stress, alcohol,36-39 caffeine, gluten antibodies,40-43 infections (beta strep, HIV), low vitamin E, medications (lithium, beta blockers, antimalarials)44-47

Table 1: Signs and Possible Nutritional Abnormality or Associated Conditions3-11

*Folate = Folic acid and/or folates throughout this document.

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 5© 2016 The Institute for Functional Medicine

Sign

Nutrition-Associated Deficiency or Consideration

Nutrition-Related Conditions and Other Associations (partial listing)

Texture (cont.)

Xerosis (dry skin)— dull color, rough texture, increased evaporation from stratum corneum,48 skin itching and tightness. Chronic or severe xerosis progresses to cause scaling and fissures, increasing the risk for inflammation and infections.49 Eczema Craquele— cracks in keratin layer.

n Vitamins A, C,50 zinc, B vitamins, EFAsn Consider cofactors, adequacy of

elongases and desaturases23-29

n UV radiation, detergents, chlorine, low humidity, chemical exposure, frequent over bathing with prolonged water emersion.

n Decreased sebum production, hyaluronic acid, and cerebride level.20

n Hyperthyroidism, uremia, Whipple’s disease, celiac disease, acrodermatitis, enteropathica

Thickness

Cellophane appearance— thin and translucent

Protein Steroids, Cushinoid

Thick Callus EFA Environmental stress, hypothyroidism

Color

Acanthosis nigricans— hyperpigmentation in skin creases—neck, axilla, bridge of the nose, elbows51,52

Excess niacin,53-56 glucose57,58 Steroid use, obesity,57 endocrine -related syndromes: insulin-resistant (IR) states, diabetes mellitus (DM),58 pinealoma, hyperandrogenic states, acromegaly, Cushing’s disease, hypothyroidism, Addison’s disease, hypogonadal syndrome with IR, Prader-Willi syndrome; malignancy

Ecchymosis > 2 mm diameter

Vitamins C, K Alcoholism, scurvy, malabsorption syndromes, liver disease

Erythema with swelling (Casal’s necklace)

Niacin, tryptophan Inflammatory bowel disease, pellagra, liver disease

Gray-tan, bronze, blue-gray—in areas of scars, flexor folds and areas exposed to the sun

Excess iron Hemochromotosis; blue-gray pigment also seen with use of high doses of minocycline

Hyperpigmentation—sun exposed areas, patchy

Protein, B12, folate, niacin Hyperthyroidism, alcoholism, Kwashiorkor in fair-skinned patients, pellagra, porphyria, drug reaction

Hypopigmentation—Hypomelanization of skin

Protein energy malnutrition Acrodermatitis enteropathica, seborrheic dermatitis, Langerhans cell histiocytosis

Lackluster skin Omega 3 fatty acids

Lemon-yellow palm creases

B12 Malabsorption syndromes, pernicious anemia

Pallor—loss of color Iron, B6, B12, folate Anemia, hypopigmentation syndromes, poor phytonutrient intake

Pallor of lips, conjunctiva, nail beds

Copper, iron, folate, B12 Alcoholism, Plummer-Vinson syndrome, anemia, malabsorption syndromes, low volume hypoperfusion state, hemorrhage

Petechiae—small capillary hemorrhages (<2 mm with Hess Test)59

Vitamin C, K59-62 Alcoholism, scurvy, liver disease, drug-induced coagulopathies

Table 1: Signs and Possible Nutritional Abnormality or Associated Conditions3-11 (cont.)

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 6© 2016 The Institute for Functional Medicine

Sign

Nutrition-Associated Deficiency or Consideration

Nutrition-Related Conditions and Other Associations (partial listing)

Color

Purpura—large areas in groups

Vitamin C, K59-62 Alcoholism, scurvy, liver disease, drug-induced coagulopathies

Red-brown scaly dermatitis—stocking/glove distribution; erythema; blister formation with peeling sunburn; dry, scaly when sun-exposed

Niacin or tryptophan Pellagra, liver disease, porphyria, cutaneous tarde

Vitiligo—Vitaligo A- generalized; B- segmental, asymmetric

B1263 n Autoimmune or endocrine disease (hypothyroidism, Graves’ disease, Addison’s disease, pernicious anemia, insulin-dependent DM)

n Thyroid issues in 30% of vitiligo patients. n Antithyroglobulin, antimicrosomal and

antiparietal cell antibodies in >50% of patients (malabsorption issues, chemical-induced, leprosy, pityriasis alba)

Yellow (carotenoderma)—first on the face, nasolabial folds, and forehead and then diffusely including creases of the palms and feet. Spares mucous membranes like sclera. Associated with yellowing of sweat.

Excess carotene Liver disease with jaundice, hypothyroidism, anorexia nervosa

Hydration

Dry tongue/mucous membranes

Dehydration (volume depletion) DM, bowel obstruction, renal failure, malabsorption syndromes

Pitting edema—lower extremities, sacrum, face

n Protein, sodium, thiaminen Over-hydration

Liver disease, renal disease, kwashiorkor, beriberi. Non-pitting edema-hypothyroid-myxedema64

Reduced turgor Dehydration secondary to poor intake or increased loss

Malabsorption, DM, bowel obstruction, renal failure, dementia

Elasticity

Hyperelasticity Vitamin C has successfully treated Type 4 only65-66

Ehlos-Daniels syndrome subtypes 1–7,67 Marfans and cutix laxis syndromes

Hair Distribution/Character

Alopecia Protein, biotin,68 iron,69 zinc,70 copper Autoantibodies (gluten, thyroid), hypothyroid, syphilis, traction alopecia, moniletrix, androgenic alopecia, lupus, discoid lupus, dermatomyositis, tinea capitis, smoking71

Banded hair (altered light and dark hair), signa de bandera, flag sign

Intermittent protein deficiency Chemical processing, bleached hair, chloroquine effects

Corkscrew hairs72-73 unemerged coiled hairs.

Vitamin C Steroids, tinea capitis,74 rare autosomal disorders75

Table 1: Signs and Possible Nutritional Abnormality or Associated Conditions3-11 (cont.)

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 7© 2016 The Institute for Functional Medicine

Sign

Nutrition-Associated Deficiency or Consideration

Nutrition-Related Conditions and Other Associations (partial listing)

Hair Distribution/Character (cont.)

Easily pluckable Protein Hypothyroidism, chemotherapy, dye/color treatment

Female pattern alopecia76 Iron, zinc, vitamin D, vitamin A, vitamin C, biotin, folic acid

Hypothyroid, alopecia ariata, syphilis, traction alopecia, moniletrix, androgenic alopecia, lupus, discoid lupus, dermatomyositis, tinea capitis

Graying (premature)— < 40 years of age

Copper Genetic, oxidative stress,71,77 smoking, UV light

Lack of luster (dull) Protein, iron Chemical effects

Menke’s kinky hair Copper Menke’s syndrome

Sparse hair n Protein, biotin, zincn Excess vitamin A

Genetics, medications, endocrine disruption (thyroid, androgens), large differential

Swan neck hairs Vitamin C

Nutrition-Associated Lesions

Acne vulgaris EFA,78 zinc,79 selenium, Vitamins A,80-82 E,80 B6,83 C,84 pantothenic acid85

Dysbiosis,51,86 Iododerma (Iodine excess),87-89 chloracne (dioxin), Vitamin A excess

Acneiform lesions Vitamin A toxicityIodine toxicity (Iododerma)

Bromine excess, chloracne, androgen excess (testosterone)

Decubitus ulcers—consider edema, shear force, hypooxygenation, over- or undernutrition, infection

Protein, arginine, zinc, vitamin C Cancer cachexia, alcoholism, AIDS, malnourishment

Delayed wound healing Protein, arginine, omega-6 fatty acids, calcium, magnesium, zinc, copper, iron, vitamins A, D, C, B1290-92

Protein energy malnutrition, inflammatory bowel disease, malabsorption, DM, alcoholism, cancer, adverse reaction to radiation (soft tissue radionecrosis)

Dermatographia n Normal, heavy metal toxicity (mercury), histamine-rich diet, allergy, drug sensitivity, mast cell degranulation conditions93-95

n All skin tests appear positive if significant dermatographia

Ecchymosis due to capillary fragility

Vitamin C, K Trauma

Macular pigmentation—all skin tones with thickening, inelastic, fissured sun-exposed skin

Niacin, tryptophan n Thermal, sun, or chemical burns n Addison’s disease

Petechiae Vitamin C, K Compression- or pressure-associated trauma, bleeding dyscrasia, coagulopathy

Pruritis—itching anus, arms, ear canals, eyes, feet, hands, legs, nipples, nose, penis, roof of the mouth, scalp, throat, generalized

IgE food allergy, hyperbilirubinemia, liver disease, porphyria, other environmental triggers, parasites

Table 1: Signs and Possible Nutritional Abnormality or Associated Conditions3-11 (cont.)

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 8© 2016 The Institute for Functional Medicine

Sign

Nutrition-Associated Deficiency or Consideration

Nutrition-Related Conditions and Other Associations (partial listing)

Nutrition-Associated Lesions (cont.)

Purpura due to capillary fragility

EFA, Vitamin C or K96 Trauma

Spider angiomas B vitamins Liver disease, pregnancy, normal variation

Warts (HPV)—plantar, palmar, common, flat, oral, respiratory papillomatosis, mucosal variants

Zinc,97,98 folate99 Primary immunodeficiencies (e.g., hyper IgE syndrome, lymphopenia, hypoimmunoglobulin G, low CD4 levels, GATA2 deficiency)100

Xanthelasma101—orange-yellow macules, papules, or nodules, symmetric on the outer third of the upper or lower eyelids

Excessive sugar, saturated fat, higher-caloric diet promotes the formation of Type 1 hyperlipidemia101

Hyperlipidemia; hypertriglyceridemia seen in hyperlipidemia types I, II, IV, and rarely III; DM; estrogen therapy; obesity

Xanthoma (eruptive)101—on buttocks, elbows, knees; clears when triglycerides return to normal.

Retinoid toxicity; excessive alcohol, sugar, or saturated fat; higher-caloric diet promotes the formation of Type 1 hyperlipidemia101

Hyperlipidemia; hypertriglyceridemia seen in hyperlipidemia types I, II, IV, and rarely III; DM; estrogen therapy; obesity

Xanthoma (planar)101—palms and palmar creases, eyelids, face, neck, chest

Excessive sugar or saturated fat; higher-caloric diet promotes the formation of hyperlipidemia but has minimal impact in type III101

Biliary cirrhosis, hyperlipidemia type III (increased cholesterol, increased triglycerides)

Xanthoma (tendinous)101—nodules involving elbows,knees, Achilles tendon,dorsum of hands and feet

Excessive sugar or saturated fat; higher-caloric diet promotes the formation of hyperlipidemia101

Hypertriglyceridemia (familial or acquired), familial hypercholesterolemia (type II—hypercholesterolemia, mild to moderate hypertriglyceridemia) or type III (see above), biliary cirrhosis

Xanthoma (tuberous)101—plaque like or nodular lipid deposits in dermous or subcutaneous tissue of the elbows or knees

Excessive sugar or saturated fat; higher-caloric diet promotes the formation of hyperlipidemia101

Hypertriglyceridemia (familial or acquired), familial hypercholesterolemia (type II—hypercholesterolemia, mild to moderate hypertriglyceridemia) or type III (see above), biliary cirrhosis

Table 1: Signs and Possible Nutritional Abnormality or Associated Conditions3-11 (cont.)

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 9© 2016 The Institute for Functional Medicine

Table 2: Points of Connection—Skin and Systemic Patterns of Nutrient Deficiency or Insufficiency11

Nutrient Symptoms or Findings (Partial list)

Macronutrients

Protein energy malnutrition

n Skin: dry, thin, loose, wrinkledn Hair: fine brittle hair, alopecian Nails: fissuring and impaired growthn Mouth: angular cheilitis, loss of buccal fatn GI: abdominal distension and occasional rectal prolapse, diarrhea, constipationn Musculoskeletal: loss of subcutaneous fat and muscle massn General: failure to thrive

Protein energy malnutrition with edema

n Skin: generalized dermatitis, “flaking enamel paint” or “cracked pavement” dermatitis, edema, increased pigmentation on arms and legs

n Hair: dark brown hair becomes a rusty red, light colored hair becomes blonde (flag sign)n GI: distention of abdomenn Neurologic: irritability, lethargy, apathyn General: failure to thrive

Essential fatty acid deficiency102

n Skin: xerosis, scaly, diffuse erythema, poor wound healing, traumatic purpura, alopecia103

n Nails: brittle nailsn Neurologic: associated with attention deficit disorder104-106

Micronutrients

Copper deficiency(genetic—Menke’s disease)

n Skin: hypopigmentation, follicular hyperkeratosis, inelastic depigmented skin at nape of neck, axillae, trunk

n Hair: kinky or steel-wool hair: short, sparse, lusterless, tangled, depigmentedn Mouth: arched palate, delayed tooth eruptionn Musculoskeletal: hypotonian Neurologic: ptosis, reduced facial movements, multifocal degenerative disease of grey

matter, demyelinating disease, ataxia, hypotonia, seizuresn General: failure to thrive, developmental delayn Genetic: Menkes gene on chromosome X q13; P-type ATPase

Copper deficiency (acquired)107-110

n Skin: poor wound healingn Hair: hair loss, alopecian Musculoskeletal: muscle and joint painn Hematologic: anemia and neutropenian Neurologic: optic neuropathy, myelopathy, parasthesias, carpel tunnel syndromen General: fatigue

Iron deficiency n Skin: generalized pruritusn Hair: lusterless, dry, focally narrow and split hair shafts, heterochromia of black hair, hair

loss (alopecia) or thinningn Nails: fragile, longitudinally ridged, lamellated brittle nails with thinning, flattening of nail

plates, koilonychiasn Ocular: blue scleraen Mouth: aphthous stomatitis, angular stomatitis, glossodynia, atrophied tongue papillae

Zinc deficiency (genetic—acrodermatitis enteropathica)

n Skin: eczematous and erosive dermatitis, preferentially localized to periorificial and acral areas, alopecia, superinfection with Candida albicans and Staphylococcus aureus

n GI: diarrhean Neurologic: irritability, whining and cryingn General: lethargyn Genetic: defect in the intestinal zinc transporter (ZIP4)

Points of ConnectionRarely does a physical exam finding occur in isolation. Usually with nutrition-associated changes, the physical exam will reveal that multiple systems are affected. Tables 2 and 3 summarize some of the classic nutrient-specific patterns that are still missed in many populations (even in affluent socioeconomic groups). Medical conditions; previous surgeries that affect nutrient availability, requirements, and utilization; medications, disordered eating patterns; socioeconomic-affected food availability; and destructive habits all alter susceptibility.

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IFM n Skin Exam n N Sight Videos and Resources: nsight.org 10© 2016 The Institute for Functional Medicine

Nutrient Symptoms or Findings (Partial list)

Micronutrients (cont.)

Zinc deficiency (acquired) n Skin: psoriasiform dermatitis involving the hands and feet and occasionally the knees; dry, scaly, eczematous skin around buttocks, enlarged fingers with paronychia, bright erythema of the terminal phalanges, poor wound healing, warts

n Ocular: abnormal dark adaptationn GI: diarrhean Reproductive: hypogonadism in malesn Neurologic: impaired mentation, dysgeusia

Vitamin A deficiency n Skin: xerosis, skin fissuring (dermatomalacia), phrynoderma, perifollicular hyperkeratosisn Ocular: impaired dark adaptation, exopthalmia, corneal xerosis, ulceration,

keratomalacia, corneal perforation, blindnessn Mouth: xerostomian Musculoskeletal: hypotonian Neurologic: hypogeusia

Thiamine, Vitamin B1 deficiency (beriberi)

n Skin: edema of face, sacrum; decreased sweating or hyperhidrosis; atrophy of the skin with distal extremity hair loss

n Cardiovascular: tachycardia, CHF, cyanosis.n Respiratory: occasional pulmonary hypertensionn GI: anorexia, vomiting, diarrhean Neurologic: irritability, apathy, restlessness; Wernicke’s encephalopathy; ophthalmoplegia,

ataxia, nystagmus, laryngeal nerve paralysis (aphonia—especially in infant beriberi)Adult: n Dry form: symmetric distal peripheral neuropathy, sensory and motorn Wet beriberi: neuropathy with cardiac involvement

n General: irritability, apathy, restlessness

Riboflavin, Vitamin B2 deficiency

n Acute: n Skin: erythema, epidermal necrolysis, mucositis

n Chronic:n Skin: seborrheic dermatitis of nasolabial folds, nostrils, nasal bridge, forehead,

cheeks, posterior auricular areas, flexural areas of limbs and genitalian Mouth: angular stomatitis, cheilosis with erythema, xerosis, fissuring, glossitis,

magenta tonguen Neurologic: photophobia

Niacin, Vitamin B3 deficiency (pellagra)

n Skin: painful pruritic dermatitis of sun-exposed skin—scaly, dry, atrophic, in intertriginous areas, dorsum of the hands (gauntlet); dorsum of feet (gaiter) macerations and abrasions may occur; Casal’s necklace in the neckline exposed to sun leads to dermatitis with erythema and hyperpigmentation; malar suborbital pigmentation (butterfly distribution), scrotal dermatitis, erythema, and hyperpigmentation

n Mouth: angular stomatitis, cheilitis, glossitisn GI: diarrhea, nausea, vomiting, abdominal pain, anorexian Neurologic: nervousness, apathy, impaired memory, depression, psychosis, dementian General: insomnia, fatigue

Folate, Vitamin B9 deficiency

n Skin: perirectal ulcerations, perineal seborrheic dermatitis, diffuse brown hyperpigmentation concentrated in the palmer creases and flexures111-112

n Mouth: glossitis with atrophy of the filiform papillae, angular cheilitis, mucosal ulcerationn GI: diarrhean Hematologic: macrocytosis, neutropenian Neurologic: (cerebral folate deficiency): seizures, neurologic delay, depression, anxiety;

MTHFR SNPs associated with functional folate deficiency

Vitamin B12 deficiency n Skin: cutaneous hyperpigmentation—diffuse, symmetric or scattered macules with greatest concentration on hands, nails, face, palmar creases, flexural regions, and pressure points; vitiligo or hypopigmentation

n Hair: hair depigmentation—localized or diffusen Mouth: glossitis—atrophic red painful with atrophy of the filiform papillae in early states

may be linear glossitis, angular cheilitisn Hematologic: macrocytic anemian Neurologic: generalized weakness with paresthesias progressing to ataxia, symmetric loss of

vibration, proprioception worse in the lower extremities and progressing to spasticity, paraplegia and incontinence; associated apathy, somnolence, irritability, memory loss, dementia, psychosis

Table 2: Classic Patterns of Nutrient Deficiency Signs with Skin and Other Associated Findings11 (cont.)

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Table 2: Classic Patterns of Nutrient Deficiency Signs with Skin and Other Associated Findings11 (cont.)

Nutrient Symptoms or Findings (Partial list)

Micronutrients (cont.)

Biotin73 and multiple carboxylase deficiency

n Skin: erythematous, crusting, scaly dermatitis around eyes, nose, mouth and periorificial areas, alopecia, glossitis, conjunctivitis

n Neurologic: irritability, lethargy, paresthesia, hypotonian General: developmental delay

Vitamin C deficiency(scurvy)

n Skin: follicular keratotic plugging, perifollicular purpura, lower-extremity edema with ecchymosis, poor wound healing, dehiscence

n Hair: corkscrew hairs, swan-neck hairsn Nose: epistaxisn Mouth: mucosal swelling, ecchymosis and bleeding of gingiva, hemorrhagic gingivitis,

necrosis, loss of teethn GI: gastrointestinal hemorrhagen Urinary: hematurian Musculoskeletal: intra-articular, subperiosteal, intramuscular hemorrhages; disruption of

growth plates; bowing of bones; depressed sternumn Neurologic: cerebral hemorrhage

Table 3: Points of Connection—Skin and Systemic Patterns of Nutrient Toxicity11,113

Nutrient Symptoms or Findings (Partial list)

Minerals

Calcium n No skin findingsn Musculoskeletal: calcification of soft tissues

Chromium n Skin: chrome ulcers (with direct contact), perforation of nasal septum (if inhaled)n Respiratory: lung cancer (hexavalent)

Copper n No skin findingsn Genetic (Wilsons disease—ATP7B protein deficient)

n Ocular: Kayser-Fleisher ring n GI: cirrhosisn Urinary: renal failuren Hematologic: anemian Neurologic: tremors, dysarthria, rigidity, choreoapthetioid movements, dementia

Fluoride n No skin findingsn Mouth: fluorosisn Musculoskeletal: stiffness, joint pain, chronic pain, long bone osteoporosis

Iodine n Skin: iododerma acneiform lesionsn General: iodine goiter, myxedema (especially in Hashimoto’s thyroiditis)

Iron n Chronic:n Skin: slate grayn Cardiovascular: cardiomyopathyn GI: enlarged livern Endocrine: diabetes, pituitary failure, testicular atrophyn Neurologic: drowsiness, shock

n Acute:n GI: upper abdominal pain, vomiting, diarrhea

Magnesium n No skin findingsn Cardiovascular: Hypertension, cardiac arrestn Respiratory: Respiratory depressionn Neurologic: disappearance of deep tendon reflexes

Manganese n No skin findingsn GI: anorexian Musculoskeletal: arthralgias, muscle weaknessn Neurologic: insomnia, depression, delusions, Parkinson’s

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Table 3: Points of Connection—Skin and Systemic Patterns of Nutrient Toxicity11,113 (cont.)

Nutrient Symptoms or Findings (Partial list)

Minerals (cont.)

Molybdenum n No skin findingsn Musculoskeletal: goutlike syndrome (at intakes > 10–15 mg/day)

Phosphorus n No skin findingsn Musculoskeletal: calcification of soft tissues

Potassium n No skin findingsn Cardiovascular: ventricular arrhythmias

Selenium n Skin: loss of hair and nails, leukonychian Neurologic: polyneuritisn General: fatigue

Zinc n No skin findingsn GI: nausea, vomiting, diarrhea

Vitamins

Vitamin A n Skin: dry, scaly with desquamation, pruritus, peeling of palms and soles, follicular hyperkeratosis, cheilitis, fissuring of lips and at the angles of the mouth, alopecia, acne

n Hair: alopecia and coarsening of the hairn Mouth: gingival discolorationn GI: anorexia, nausea, vomiting, hepatomegaly, splenomegalyn Musculoskeletal: myalgias, arthralgias, premature closure of the epiphyses, spontaneous

bone fractures, subperiosteal bone growth, cortical thickeningn Hematologic: anemian Neurologic: blurred vision, diplopia, pseudotumor cerebrin General: nausea, anorexia, weight loss

Beta Carotene n Skin: yellow or orange discoloration of the skin—xanthosis cutis or carotenoderma in the nasolabial folds, forehead, axillae, groin, palms, and soles of the feet

Thiamine, Vitamin B1 n No skin findings or other associated toxicities

Riboflavin, Vitamin B2 n No toxicity findings noted

Niacin, Vitamin B3 n Skin: vasodilation, flushing, pruritus, blistering of the skin with brown pigmentation, acanthosis nigricans

n GI: nausea, vomiting, liver dysfunction with hypertransaminasemia

Pyridoxine, Vitamin B6 (pyridoxine HCl)

n No skin findingsn Neurologic: sensory neuropathy, progressive sensory ataxia, lower-limb impairment of

position and vibratory sense; touch, temperature, and pain perception less affected

Folic Acid, Vitamin B9 (synthetic)

n No skin findingsn Neurologic: anxiety (associated with COMT and other one-carbon metabolism SNPs)

B12 (cyanocobalamin) n Skin: acne, rosacea fulminans, dyshidrotic eczema, cheilitis, stomatitis

Biotin n No skin findings or other associated toxicities

Vitamin C n No skin findingsn GI: diarrhea

Vitamin D n No skin findingsn GI: anorexia, nausea, vomiting, constipationn Urinary: polyuria, polydipsian Neurologic: stupor, hyperesthesian General: weakness, hypotonia, hypertensionn In infants: mental retardation, stenosis of the aorta, and elfin facies

Vitamin E n No skin findingsn In infants: necrotizing enterocolitis

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Further Clinical EvaluationHess Test: The Hess test is a screening tool originally devised for clinical evaluation of scurvy.62 It documents the number of petechiae 10 cm below the antecubital fossa crease (or at the bicep tendon insertion) that develop after 3–5 minutes of a sustained increased pressure placed on the arm by a blood pressure cuff inflated midway between the patient’s systolic and diastolic readings (80 in children, 100 mmHg in most adults). The development of petechiae is associated with the nutritional condition of vitamin C insufficiency, but also a number of other causes for coagulopathy, basement membrane weakness, or capillary friability. The presence of >7 new petechiae in women or >10 in males leads the clinician to consider vitamin C insufficiency in the contributing conditions. The addition of a gram of vitamin C should normalize an abnormal Hess test within 6 weeks.62 If there is no resolution with increased vitamin C intake, then additional causes of capillary friability need to be considered.

Potassium Hydroxide Solution Test: Performed by taking a simple scraping of a lesion with a glass slide, transferring some of the collected sample onto another slide and placing 1 or 2 drops of 10–20% potassium hydroxide solution on the sample, then warming the slide with a match. The heat of the match allows the visualization of yeast hyphae.7,8 A similar collection with normal saline and a cover slip allows the viewing of bacterial load on the sample and might direct the clinician to perform further evaluation (culturing for yeast, anaerobic or aerobic bacteria).

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Figure 1: Acne, Personal Lifestyle Factors, and Clinical Imbalances

Physiology and Function: Organizing the Patient’s Clinical Imbalances

Retelling the Patient’s Story

AntecedentsSNPs associated with zinc, beta carotene, vitamin A Elongases/desaturases a�ecting EFA metabolism

Triggering EventsAndrogens, dairy-associated growth hormones, antibiotic-associated dysbiosis,

Mediators/PerpetuatorsDysbiosis associated with antibiotic use Epilepsy, NIDM, IDDM

Name: Date: CC: © 2016 Institute for Functional Medicine

Modi�able Personal Lifestyle Factors

Exercise & Movement NutritionDiet high in allergens, dairy, sugar/re�ned carbohydrates, fried foods EFA de�ciency Low nutrient density

StressHigh stress, adrenaline HPA axis stimulation

RelationshipsSleep & RelaxationCircadian rhythm disruptionInadequate sleep

FUNCTIONAL MEDICINE MATRIX

Acne

AssimilationDysbiosis, maldigestion, malabsorption, bile salt insu�ciency, fatty acid malabsorption, PPI use

Defense & RepairFood sensitivities/allergies Small intestinal bacterial overgrowth (SIBO)

EnergyEnergy Regulation, Mitochondrial Function

Structural IntegritySebum, low perspiration �ow, xerosis

CommunicationHormone imbalance, testosterone dominance, insulin resistance Hyperadrenalism,elevated cortisol, driven by insulin-like growth factor I (IGF-I)

Biotransformation & EliminationImpaired elimination of toxins (e.g., Dioxins) Gut-derived endotoxins (e.g., Lipopolysaccharides)

TransportLack of sebum formation Bacterial overgrowth in pores

Mental Emotional

Spiritual

‘Acne personality’ that predates disease onset and increases the likelihood of stress reactivity, anxiety, and depression associated with acne

Functional Medicine MatrixEvery finding on the physical exam can be evaluated through the Functional Medicine lens, looking for unique antecedents, triggering events, perpetuating factors, and lifestyle influences that point to system clinical imbalances. In Figure 1, the skin condition acne vulgaris is placed onto the Functional Medicine matrix tool. This demonstrates how a common skin finding can represent a broad array of physiological and functional imbalances and is influenced by antecendents, triggers. mediators (ATM’s) and modifiable lifestyle factors.

ConclusionAn unhealthy skin and its lesions can represent a myriad of pathways and pathologies altering the healthy macro- or micronutrient balance. If the skin is turning over too rapidly (psoriasis) or its regeneration is too slow (chronic wounds), the macronutrients and micronutrients involved in the multiple biochemical pathways may produce cutaneous and extracutaneous consequences. The skin portion of the functional nutrition evaluation of the patient helps integrate the clinical exam with the patient’s diet, lifestyle, history, and timeline and reveal factors of system balance that promote health or disease.

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Acknowledgements IFM would like to acknowledge and thank the development team for their research, organization, and creation of the ABCDs of Functional Nutrition Physical Exam series. P. Michael Stone MD, MS and topic specific contributors developed the materials. The Functional Nutrition Evaluation; Skin Exam materials were co-developed with Elizabeth Boham, MD, MS. The development team also included Kristi Hughes, ND, Nicole Dotson, ND, Deanna Minich, PhD, and Nicholas Morgan, ND, who all did excellent work in support of the materials.

To cite: Stone PM, Boham E: Functional Nutrition Evaluation; Clinical Indicators: Skin Exam Companion Guide. Federal Way (WA): Institute for Functional Medicine: 2016.

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The skin is a dynamic, protective, and integrated sensing and absorbing layer. What we eat and how well we balance our lives are reflected in our skin. The changes found on our skin are often ... more than skin deep. — Michael Stone, MD, MS

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