red spots on skin

What is your skin trying to tell you?

Internal diseases and cancers can have numerous manifestations on our skin. What is this gentleman’s skin trying to tell us?

He is an elderly hospitalized male in his 80s, admitted for urinary tract infection. He has underlying Diabetes, type II, and End-Stage Kidney Disease requiring regular dialysis. He is not very mobile at baseline and resides at an assisted living facility. I was consulted for rash on left leg that was concerning for vasculitis, a condition that causes inflammation and leakage of blood from blood vessels in skin or internal organs. Since this condition can have multiple causes, as well as worrisome sequelae, it is important to diagnose and treat it in a timely fashion.

On exam, the rash consisting of red hard crusty spots, directly on each hair follicle opening, and coiled hair fibers. The brawny pigmentation on lower legs was noted to be from diabetic dermopathy, which is typical in patients with long-standing or uncontrolled diabetes. I was not convinced that the rash was typical of vasculitis. I ordered a check of his vitamin C levels which came back as undetectable. This gentleman, who was largely nonverbal during exam, and only spoke to ask for orange juice repeatedly, was deficient in vitamin C. He had scurvy!

Scurvy is a vitamin C (sscrobic acid) deficiency that can present with pin-point bleeding in skin, gums, and other tissues, easy bruising, gingivitis, muscle pains, and poor wound healing. It can also cause anemia, which was also present in our patient. Patients with poor oral intake, restricted diets, underlying malnourishment, defects in gut’s ability to absorb certain vitamins, and increased alcohol intake can all contribute to development of scurvy. Vitamin C is normally found in citrus fruits, tomatoes, potatoes, brussel sprouts, cauliflower, broccoli, strawberries, cabbage, and spinach. Treatment of scurvy is with vitamin C-rich foods and supplementation with 500 mg tablets twice daily for a few weeks in adults. It usually corrects itself in a few weeks.

Skin can have interesting manifestations of internal diseases and cancers. In this case, his skin presented with interesting findings of vitamin C deficiency. He was craving orange juice for a reason after all!