Zinc deficiency and its management in the pediatric population: A literature review and proposed etiologic classification

doi:10.1016/j.jaad.2013.04.028

Journal of the American Academy of Dermatology

Volume 69, Issue 4, October 2013, Pages 616-624.e1

https://doi.org/10.1016/j.jaad.2013.04.028 Get rights and content

Zinc is a trace element essential to the gastrointestinal, immune, integumentary, reproductive, and central nervous systems. Zinc deficiency is prevalent in many areas of the world and is a diagnostically challenging condition. Cutaneous manifestations typically occur in moderate to severe zinc deficiency and present as alopecia and dermatitis in the perioral, acral, and perineal regions. Zinc deficiency is a potentially fatal disease process. The aim of this review is to focus on the cutaneous manifestations, diagnosis, and treatment of zinc deficiency in children, and to propose an etiologic classification system.

Section snippets

Zinc metabolism

Zinc is tightly regulated within the body by transporters that work primarily in the duodenum, jejunum, and nephron.1, 15, 16, 17 There are 2 types of zinc transporters, coded from solute-linked carrier (SLC) gene families, which possess competing roles in zinc homeostasis.1, 15, 16, 17 ZnT transporters (SLC30) function by reducing intracellular zinc concentrations, whereas Zip transporters (SLC39) function to increase intracellular zinc.1, 15, 16, 17 There are 9 known ZnT and 15 Zip

Dietary zinc

A variety of food sources and their zinc content are listed in Table II (available at http://www.jaad.org).

Zinc preparations

Supplements containing elemental zinc are available for treatment of zinc deficiency. The most widely available products include zinc oxide, zinc acetate, zinc sulfate, and zinc gluconate, which contain elemental zinc percentages of 80%, 30%, 23%, and 14.3%, respectively.

Anti-inflammatory and antioxidant properties

Reactive oxygen species (ROS), such as superoxide, hydrogen peroxide, and hydroxide, are by-products of aerobic metabolism. These species create oxidative damage to cells and have been shown to contribute to neurodegeneration, carcinogenesis, aging, and atherosclerosis.27, 28, 29 Zinc acts to prevent ROS formation by inhibiting enzymes, such as nicotinamide adenine dinucleotide phosphate oxidases, that catalyze the formation of superoxide from oxygen.²⁷ Further, it is a key component in

Clinical presentation of zinc deficiency

Symptoms of zinc deficiency are highly variable and depend on severity. The cutaneous eruption (Fig 1) represents the classic clinical presentation. Both cutaneous and noncutaneous features of zinc deficiency are outlined in Table III.

Laboratory values

Zinc deficiency may be diagnosed by clinical history and examination. Laboratory testing, response to zinc supplementation, and cutaneous histopathology can help to confirm the diagnosis.

Up to 60% to 80% of serum zinc is bound to albumin; thus, the zinc value should be corrected for any concurrent decrease in the patient’s albumin levels.¹ Plasma zinc is considered to be deficient below 70 μg/dL (10.71 μmol/L) for morning fasting samples and below 65 μg/dL (9.95 μmol/L) for nonfasting samples.22

Treatment

Approximately 70% of patients with zinc deficiency respond positively to zinc supplementation if initiated within 6 months of onset.⁵⁸ The skin lesions heal without permanent sequelae, but extended periods of deficiency may have permanent effects on growth and development in children.58, 89 Studies of zinc deprivation on rats demonstrated reduced motor activity, decreased brain mass, and short-term memory loss persisting from early life to adulthood.⁹⁰ Similar experiments in mice showed stunted

Conclusion

Zinc deficiency can be a diagnostically challenging condition. We believe our proposed etiologic classification system may help facilitate the diagnosis and management of zinc deficiency in children.

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ReviewZinc deficiency and its management in the pediatric population: A literature review and proposed etiologic classification

Section snippets

Zinc metabolism

Dietary zinc

Zinc preparations

Anti-inflammatory and antioxidant properties

Clinical presentation of zinc deficiency

Laboratory values

Treatment

Conclusion

J Trace Elem Med Biol

J Pediatr

Am J Hum Genet

J Am Acad Dermatol

Am J Clin Nutr

J Nutr

J Nutr

Free Radic Biol Med

Free Radic Biol Med

J Surg Res

Arch Biochem Biophys

Hum Pathol

J Invest Dermatol

Int J Biochem Cell Biol

Clin Dermatol

J Biol Chem

J Nutr

Am J Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

J Nutr

Am J Clin Nutr

J Biol Chem

J Pediatr

Am J Clin Nutr

Mutat Res

Am J Clin Nutr

J Nutr

Am J Clin Nutr

Prog Brain Res

Am J Clin Nutr

Zinc deficiency

Curr Opin Gastroenterol

Understanding zinc: recent observations and interpretations

J Lab Clin Med

Mild human zinc deficiency produces an imbalance between cell-mediated and humoral immunity

Nutr Rev

Zinc: an overview

J Nutr

Zinc deficiency and taste disorders

Ann Pharmacother

Zinc, human diseases and aging

Aging (Milano)

Zinc deficiency: changes in cytokine production and T-cell subpopulations in patients with head and neck cancer and in noncancer subjects

Proc Assoc Am Physician

Zinc and human health: an update

Arch Toxicol

The biochemical basis of zinc physiology

Physiol Rev

Use of national food balance data to estimate the adequacy of zinc in national food supplies: methodology and regional estimates

Public Health Nutr

Clinical spectrum of human zinc deficiency

Dietary zinc absorption: a play of Zips and ZnTs in the gut

IUBMB Life

Mammalian zinc transporters

Annu Rev Nutr

Responsive transporter genes within the murine intestinal-pancreatic axis form a basis of zinc homeostasis

Proc Natl Acad Sci U S A

Review
Zinc deficiency and its management in the pediatric population: A literature review and proposed etiologic classification