CORN FLAKES IS THE CURE

Editor,

We report a case of vitamin C deficiency, otherwise known as scurvy, presenting with cutaneous findings. Vitamin C is vital for skin health and a deficiency leads to bleeding gums, poor wound healing, thickening of the stratum corneum and subcutaneous bleeding.¹ In severe deficiency there is a risk of haemarthrosis, subperiosteal haemorrhage and visceral bleeding, therefore, scurvy is a diagnosis not to be missed.¹ Vitamin C improves skin hydration and also has a role in reducing free radical formation triggered by ultraviolet ray exposure to the skin. This helps to reduce premature skin ageing and the occurrence of cutaneous squamous cell carcinoma.² Furthermore, reduction in free radicals helps to reduce the risk of atherosclerosis by preventing oxidation of low density lipoproteins.³ Scurvy can be confused with vasculitis or a coagulopathy, leading to unnecessary investigations and a delay in treatment. It is important to note the risk factors and clinical features to ensure an early diagnosis.

A 48-year old unemployed man presented to dermatology outpatients with a one year history of a recurring rash suspected to be cutaneous vasculitis. Curiously, our patient reported improvement in his skin changes after a spell of eating solely Kellogg’s Crunchy Nut Cornflakes^â on holiday. The cereal contains 111mg ascorbic acid per 100g of cereal, amounting to 83% of the recommended daily allowance.⁴ Our patient described his rash reappearing a few months after he returned home. The patient had a history of depression, anorexia and alcohol dependence. His medication included citalopram. Examination findings included perifollicular haemorrhages, corkscrew and swan neck hairs over his arms and legs and purpura over his thighs. (Figures 1 and 2). Investigations revealed a vitamin C level of 3.2umol/l (normal range > 32umol/l), negative anti-nuclear antibodies (ANA), negative anti-neutrophil cytoplasmic antibodies (ANCA) and normal complement levels. The patient had concurrent normocytic anaemia (haemoglobin 10.8 g/dl, MCV 91 fl). Haematinics were normal. The patient was commenced on oral ascorbic acid therapy with resolution of his skin eruption within two weeks.

Figure 1.

Perifollicular haemorrhage and corkscrew and swan neck hairs

Figure 2.

Ecchymoses and purpura on posterior thighs

Vitamin C is important for collagen metabolism, therefore, a deficiency leads to degeneration of connective tissue and vasculature, hence the clinical findings of scurvy.⁵ Once treated, bruising and perifollicular haemorrhages usually resolve within two weeks, whilst corkscrew hairs take up to four weeks to normalise.⁵ The diagnosis of scurvy has been known since ancient times, however, in 1747 Sir James Lind was the first to recognise intake of citrus fruit as prevention of the condition.⁵ It is important to note that vitamin C levels in peeled and cut fruits stored at 5°C decreases up to 25%.⁶ Scurvy is often incorrectly thought to be eradicated from developed countries, however, the prevalence of scurvy in developed countries is as much as 26%.⁷ Our patient suffered psychiatric illness, which is a reported association of scurvy. Other associations include social isolation, drug and alcohol abuse, fad diets and disorders of malabsorption.⁷