156 VITAMINS A AND CAROTENES 



In studies such as those of Pemberton^^ in England, describing a mild 

 follicular hyperkeratosis in 5 % of 3000 school children with no other indi- 

 cation of low vitamin A, the specificity of the skin lesions is questionable. 

 A report from the United States^^ deals with 9 children showing mild 

 papular lesions associated only with subnormal biophotometer readings. 

 The sex distribution, the familial tendency, amelioration during warm 

 weather, and the fact that 100,000 to 300,000 I.U. of vitamin A daily over 

 a period of 2 to 4 months effected only "nearly complete recovery" leaves 

 some doubt as to the specificity of the lesions described. The question of 

 high levels of vitamin A therapy (75,000 I.U. or more, daily) and the effect 

 upon dermatologic disorders presumably unrelated to avitamnosis A is 

 discussed in a later section (p. 159). 



A recent report by Marmelzat^'*'' from Galveston, Texas, describes a 

 rare combination of Bitot's spots, typical follicular hyperkeratosis lesions, 

 and metabolic calcinoses of both kidneys observed in a 10-year-old white 

 girl. The skin over the abdomen, thorax, posterior and lateral surfaces of 

 the arm, elbows, and knees presented minute horny papules about 2 mm. 

 in diameter, giving a "grater-like" feel to the surface. Biopsy revealed 

 moderate hyperkeratosis and keratotic plugging of sebaceous follicles. 

 There was regular nocturnal fever (100 to 102° F.) during a 4-week period 

 of observation on a high-caloric diet supplemented by iron and vitamin B 

 supplements; fever and conjunctival and skin lesions remained the same. 

 With 25,000 I.U. of vitamin A orally, the Bitot's spots disappea ed in less 

 than 24 days; after a little over 2 months, when the patient was lost from 

 observation, the follicular lesions had disappeared except for a few on the 

 arms. Although this was regarded as a conditioned deficiency, secondary 

 perhaps to giardiasis, the observations and findings closely parallel those 

 reported from Oriental countries and further confirm the generally accepted 

 relationship between avitaminosis A and follicular hyperkeratosis in chil- 

 dren. 



The frequent lack of correlation between incidence of skin lesions and of 

 other evidence of vitamin A deficiency in studies on children is probably 

 due as much to differences in and inadequacy of criteria of vitamin A de- 

 ficiency employed by the various observers as to variability within the 

 groups of children studied. No correlations have been made between age of 

 children and incidence of lesions. One must also consider the possibility 

 that, depending on the role of vitamin A depletion or the influences of 

 metabolic (diarrhea, liver dysfunction) or environmental (exposure of body 

 areas, clothing, hygiene) factors, cutaneous and ocular manifestations of 



"J. Pemherton, Lancet I, 871 (1940). 



" E. Lehman and H. G. Rapaport, J. Am. Med. Assoc. 114, 386 (1940). 



54a W. L. Marmelzat, Arch. Dermatol, and Syphilol. 63, 759 (1951). 



