Wound problems due to zinc deficiency

Abstract

Zinc deficiency, though uncommon, can occasionally present in current medical practice. A 4.5‐year‐old boy with previous gastrointestinal surgery presented with diarrhoea, disinterest and dermatitis affecting the face and perineum. The clinical diagnosis was confirmed by the presence of a low serum zinc level. Administration of parenteral zinc led to rapid improvement in diarrhoea, demeanour and dermatitis. Further surgery was then undertaken, surgery had been postponed until normalisation of zinc levels due the association between zinc deficiency and poor postoperative wound healing.

Introduction

Many nutritional deficiencies adversely impact upon wound healing, of which the most well recognised is scurvy; vitamin C deficiency. Though uncommon, nutritional deficiencies may present as complications of current medical practice.

Case

A 4·5‐year‐old boy was referred by the paediatric surgeons with painful perineal erosions that were assumed to be caused by diarrhoea. He presented with a 12‐week history of nausea, vomiting and diarrhoea followed by a 4‐week history of a worsening and painful eruption affecting the napkin area, face and hands.

He had a complicated medical and surgical history. He was diagnosed with Hirschsprung's disease aged 7 months, he had a number of operations to resect and bypass the aganglionic bowel. He had been receiving enteral feeding through a percutaneous gastrostomy for many months, which contained mineral and vitamin supplements including zinc. He was awaiting further gastrointestinal surgery with a view to an ileostomy because of the continued vomiting and diarrhoea.

Examination revealed a listless child with severe erosive perineal dermatitis, particularly around the anus (Figure 1). There was a periorbital and perioral scaly dermatitis (Figure 2). He had flaccid bullae on the face, trunk and limbs, and desquamation of the fingertips.

Figure 1.

Perianal erythema and erosions despite regular application of barrier creams.

Figure 2.

The characteristic exfoliative erythematous eruption affecting the oroficial areas, around the eyes and mouth.

A clinical diagnosis of zinc deficiency, acrodermatitis enteropathica was made. Investigation revealed a low serum zinc level of 2·3 μmol/l (normal 8–22 μmol/l) and normal selenium level, copper level, urea and electrolytes and liver‐function tests.

Further surgery was postponed and the patient was treated with intravenous zinc supplementation and the application of a barrier ointment for the napkin area dermatitis. Within 7 days, the cutaneous erosions, nausea and vomiting resolved and he was no longer listless.

Discussion

Zinc is an essential trace element for all living matter, and it is involved in the normal function of all cells. Zinc regulates DNA and RNA polymerises, thymidine kinase and ribonuclease and is an important metal moiety in many enzymes. Also, it has an important function in normal immunity and wound healing. Zinc deficiency (acrodermatitis enteropathica) may be inherited or acquired. Acquired zinc deficiency may arise due to dietary deficiency (as reported in many Middle East countries), gastrointestinal disease and gastrointestinal surgery (as in our case) and after chemotherapy (the author has seen two haematological patients with zinc deficiency during bone marrow transplantation) or in HIV infection.

Affected individuals develop a classical triad of dermatitis, depression and diarrhoea. The eruption is symmetrically distributed over the extensor surfaces of the major joints, the fingertips and perioroficially (around eyes, nose, mouth and perineum). That is characterised by erythematous erosions and blisters. Dietary, or as in our case, parenteral, zinc supplementation of 2 mg/kg/day is associated with rapid resolution of all these clinical features within 1–2 weeks (1).

Zinc deficiency has also been found to delay wound healing (2), in both patients and animal models. Surgical wounds in zinc‐deficient animals were found to be weaker and susceptible to dehiscence (3). Some advocates have even suggested that zinc supplementation should be used preoperatively in otherwise normal individuals to accelerate wound healing after surgery (4).