154 vitamins a and carotenes 



2. Macroscopic Features in Infants and Children 



The early reports dealing with xerophthalmia in infants and children 

 make only occasional reference to skin changes, and these relate chiefly to 

 dryness, wrinkling, and generalized xerosis^"^^ which to some investiga- 

 tors*°' ^^ appear to reflect dehydration and emaciation so often apparent. 

 On the other hand, following the characterization of cutaneous lesions in 

 adults there have appeared numerous reports dealing with follicular hy- 

 perkeratosis in children which are often cited as confirming the former 

 studies. It seems that inaccurate diagnosis, inadequacy of ancillary data, 

 and unjustified interpretation of data in some of these studies are largely 

 responsible for confusion and misgivings concerning the specificity of fol- 

 licular lesions as a manifestation of avitaminosis A. If one considers the 

 evidence presented separately, and apart from that pertaining to adult 

 man, it seems unnecessary to take the viewpoint of Stannus,^^ who, after 

 a critical appraisal of the literature, concluded that the cutaneous altera- 

 tions ascribed to avitaminosis A are none other than the rather common 

 dermatologic disorder, keratosis pilaris; however, he admits that inade- 

 quate vitamin A may be an important factor in the genesis of keratosis 

 pilaris under certain conditions. 



Reference has been made to a report of Frazier and Hu^^ stating that 

 follicular hyperkeratosis rarely occurred before the age of puberty, and 

 that the usual cutaneous manifestation of A deficiency in children was 

 xeroderma. A continuation of these studies,"*^ based upon routine examina- 

 tion of patients admitted to the pediatric service of Peiping Union Medical 

 College over a 5-year period, brought forth evidence that typical lesions 

 of follicular hyperkeratosis do occur before puberty, but that the degree 

 of involvement of the pilosebaceous follicle is ciuite limited in infants and 

 becomes more marked with increasing age. These conclusions are supported 

 by 5 case histories, with histologic studies of skin biopsies, illustrating the 

 maximal changes observed at successive age periods (69 days, 16 months, 

 2 years 10 months, 5 years, and 15 years of age), and recapitulating the 

 progressive phases of development of skin lesions seen in young adults. 

 Delay in functional maturity of pilosebaceous follicles and variations in 

 hormonal influences on the skin during sexual development were regarded 

 as factors modifying the effect of vitamin A deficiency upon the integument. 

 With reference to keratosis pilaris they state: "We have never included 

 instances of this minor, but widely prevalent, lesion among the cases of 

 vitamin A deficiency that we have reported." 



In contrast to the rarity of follicular eruptions in children in the experi- 

 ence of Frazier and Hu, observers in other countries have reported a rela- 



« H. S. Staiinus, Proc. Roy. Soc. Med. 38, 237 (1945). 



" C. N. Frazier, C. K. Hu, and F. Chu, Arch. Dermatol, and Syphilol. 48, 1 (1943). 



