Indian Journal of Dermatology
CASE REPORT
Year
: 2009  |  Volume : 54  |  Issue : 5  |  Page : 71--73

Carotenemia in an African lady


Arfan Ul Bari 
 Combined Military Hospital, Muzaffarabad

Correspondence Address:
Arfan Ul Bari
Combined Military Hospital, Muzaffarabad

Abstract

Carotenemia is characterized by an abnormal yellowish orange pigmentation of the skin, predominantly seen on the palms and soles. Although it may be associated with several diseases such as diabetes, hypothyroidism and anorexia nervosa, it is caused by excessive intake of carotene-rich food such as oranges and carrots in most cases. The condition is harmless, but it can lead to a mistaken diagnosis of jaundice. Herein, an interesting case of carotenemia is described in a 32-year-old female secondary to increased ingestion of oral sweet potatoes and oranges.



How to cite this article:
Ul Bari A. Carotenemia in an African lady.Indian J Dermatol 2009;54:71-73


How to cite this URL:
Ul Bari A. Carotenemia in an African lady. Indian J Dermatol [serial online] 2009 [cited 2020 Jan 22 ];54:71-73
Available from: http://www.e-ijd.org/text.asp?2009/54/5/71/45463


Full Text

 Introduction



Carotenemia is a clinical condition characterized by yellow pigmentation of the skin and increased carotene levels in the blood, mostly caused by prolonged and excessive consumption of carotene-rich foods, such as carrots, squash, and sweet potatoes, green vegetables and citrus fruits. Carotene is a lipochrome that normally adds yellow color to the skin. It is rarely associated with more serious conditions, such as diabetes mellitus and hypothyroidism. Carotenemia may be particularly evident when the stratum corneum is thickened or when the subcutaneous fat is strongly represented. Carotenemia is a benign condition and may occur at any age, but most commonly occurs in vegetarians and young children. [1],[2] Carotenes are the hydrocarbon component of carotenoids, which are pigments of plant origin and are responsible for the yellow and orange color of fruits and vegetables. Carotenoids act as antioxidants, affect cell growth regulation, and modulate gene expression and immune response. Animals are incapable of synthesizing carotenoids. Carotene derived from plant foods is the primary source of dietary vitamin A. Ingested carotenes, enclosed as crystals or amorphous solids within vegetable cells, are converted to vitamin A in the mucosal cells of the small intestine. Approximately 10% of ingested carotene is absorbed unchanged and is carried directly to the liver by portal circulation. Factors influencing the absorption of carotene include the fiber content of the plant and the particulate size of the food. Pancreatic lipase, bile acids, fat, and, possibly, thyroid hormone aid in the absorption of carotene. Cooking, pureeing, or mashing fruits and vegetables ruptures cell membranes, thereby increasing the bioavailability of carotene for absorption and, may account for an increased incidence of diet-induced carotenemia in infants. Intestinal disease and infections may impair the absorption of carotene. Ingestion of mineral oil decreases absorption, while water dispersion agents enhance absorption. [3],[4],[5] Excessive dietary intake of carotene-rich food is by far the most common cause of carotenemia. In rare cases, it results from systemic disease like, diabetes mellitus, nephritic syndrome, glomerulonephritis, hypothyroidism, anorexia nervosa and primary hepatic disease. Carotenemia may be related to restricted dietary habits, hyperlipidemia, or a deficiency in the conversion of carotene into vitamin A by the liver. [1],[2] Metabolic carotenemia without a history of excessive carotene intake may be due to a genetic defect in the metabolism of carotenoids. [5] Laboratory studies generally are not indicated in the evaluation of diet-induced carotenemia. If measured, serum carotene levels are elevated, ranging between 250-500 μg/dL a skin biopsy specimen may show autofluorescence in the superficial horny layer and a pemphiguslike pattern of intracellular autofluorescence.[5],[6] Treatment of diet-induced carotenemia consists primarily of reassuring and eliminating or restricting carotene-rich foods from the diet. Other causes are extremely rare and when suspected, direct appropriate investigation and treatment should be started. [1],[2],[3]

 Case History



A 32-year-old female reported to us with complaints of yellowish discoloration of her skin for the last three years. She initially noted yellowing of her palms, followed by similar appearance of her soles. Discoloration gradually increased in intensity and meanwhile she also started noticing of lightening of her original black (negroid) color, This lightening and yellowing of skin was more noticeable over her face and tongue. Throughout this period she never had any associated illness or any feature of ill health. There was no history of similar illness in her family. On inquiring about her diet history, she disclosed that she was much found of eating oranges, sweet potatoes and spinach. During orange season, she used to eat at least a dozen of oranges daily and spinach and sweet potatoes were the major ingredients of her daily diet. On physical examination, her face appeared relatively pale and yellow when compared with her natural black color with orange hue [Figure 1]. Tongue also showed yellowing but marked diffuse yellowish discoloration was noted over palms and soles [Figure 2]. Her blood complete examination, liver function tests, thyroid function tests and renal function tests, all were normal. Based on clinical features and absence of any associated illness, and suggestive diet history, she was diagnosed to have diet related carotenemia and was advised accordingly to avoid or restrict diet rich in carotenes.

 Discussion



In diet-induced carotenemia, elevated serum carotene often is accompanied by a corresponding elevation in serum vitamin A levels, but hypervitaminosis A is not observed presumably because the conversion of carotenoids to vitamin A is very slow. In other causes of carotenemia (associated with systemic diseases), serum vitamin A levels are within reference ranges or low.

Excessive intake of carotene (vitamin A precursors) in foods, can lead to a yellow discoloration of the skin but not of the sclera and oral cavity. The absorption of dietary carotenoid requires dietary fat and is enhanced by administering with meals. Carotenemia is more easily appreciated in light-complexioned people, but it may be difficult to appreciate it on black skin. In darkly pigmented persons, it chiefly presents as yellowing of the palms and the soles as was in case reported here. Because carotene is excreted by sebaceous glands and is present in sweat, the yellow pigmentation is particularly noticeable in areas where sweating is marked. The sclerae always are spared, which readily distinguishes carotenemia from jaundice. [3],[4],[5],[7] Diet induced carotenemia is a clinical diagnosis and laboratory confirmation is not generally required. However it can be verified by a high serum beta carotene level, a normal or slightly elevated vitamin A level, and normal liver function test results. Patient described here is a typical case of diet related carotenemia, after exclusion of other possible causes and more suggestive diet history. In this case diet responsible for the condition may be excess of any one of her favorite diets (sweat potatoes, spinach, and oranges) or it can be the combination of all three. The food items mentioned are known to have excess carotenes. Other foods described in literature that can be responsible to cause carotenemias include, green beans, supplements, papaya, asparagus, broccoli, carrots, cucumbers, lettuce, squash, apples, peaches, prunes, tomatoes, yams, butter, egg yolks, milk, and yellow corn. [1],[2],[8],[9],[10] It becomes essential, for dermatologists as well as general physician to be aware of diet related carotenemia, as it can help the provider avoid confusion with jaundice and avoid unnecessary worry and costly workup.

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