Extreme zinc deficiency – is it a vegan issue?

A recent case report from Florida (USA) starts with the sentence: “We present a case of severe acquired acrodermatitis enteropathica [caused by extreme zinc deficiency] in a vegan adult female with multiple underlying comorbidities.“
Some vegans might ask themselves (or might be asked) if they should be concerned about zinc. Short answer: No. Good sources of zinc: legumes, whole grains, nuts & seeds.

Short summary:
This person suffered from a surely very painful and extremely distressing skin rash. She was in a terrible situation of a long history of heavy alcohol use, malnutrition (also bulimia), pancreas and liver disease with resulting malabsorption of nutrients, severe lung disease and poverty. She had many allergies/food intolerances and tried to improve her situation following a (self-reported) vegan diet.
Zinc supplementation almost completely cured the rash within days.

Long summary:
  • 43 year old woman
  • lifetime history of multiple allergies, food intolerances/sensitivities, asthma, abdominal pain and diarrhea, and rash due to certain foods including dairy products.
  • diagnosed with a liver disease several months before
  • “lengthy history of alcohol abuse”
  • previously admitted due to anxiety, depression, insomnia and a history of bulimia
  • seven years ago: admitted for first attack of pancreatitis
  • three years ago: admitted again for several weeks with an attack of pancreatitis
  • “she had been adherent to a vegan diet for the last 17 years to avoid rashes and diarrhea that accompanied several types of food and in the last few years”
  • “she had been unable to afford or acquire good vitamin supplementation
  • “history of non-compliance with her pancreatic enzyme replacement regimen due to socioeconomic factors” - This would have worsened her state of malnutrition.
    long-term depression and anxiety

  • “nearly full body rash”
  • The rash spared the palms, soles, and face with the exception of tongue and lips
  • peripheral edema
  • glossitis (inflammation of the tongue)
  • cheilitis (inflammation of the lips, very cracked lips)
  • alopecia (“my hair has been falling out in chunks.”)
  • loss of appetite from the glossitis
  • increasing diarrhea
  • abdominal pain
  • concentration difficulties
  • memory problems
“the rash started on her feet and mouth before spreading to her knees and was accompanied by lower extremity swelling, cheilitis, and glossitis.”

Health issue:
Extreme zinc deficiency probably because of malabsorption but possibly also because of insufficient intake of zinc. This extreme zinc deficiency caused an extreme skin rash around the mouth, on arms and hands, and in the ano-genital area. These symptoms are the classic signs of an extreme (not mild) zinc deficiency. This type skin rash is called “acquired acrodermatitis [acro = arms and legs; dermatitis = skin inflammation] enteropathica [illness of the intestine]”.

As the authors write: “The symptoms are often extremely distressing for the patients, though the treatment is simple and clinical improvement occurs rapidly with appropriate care.”

Cause of the problem (in this case):
  • pancreatic insufficiency (possibly due to alcohol dependence and long-term very high alcohol consumption). The pancreas produces digestive enzymes. If the pancreas fails to do this, we cannot absorb nutrients from the food in our intestine.
  • Malnutrition (probably general malnutrition and underweight). Therefore low dietary intake of zinc (probably low food intake and low quality food intake – very common in people with alcohol or other substance addictions.)
  • vegan diet with “no supplementation” (probably none whatsoever)
  • various illnesses that this patient had at the same time (higher zinc requirements, plus higher zinc losses): bronchiectasis [lung problems], Mycoplasma pneumoniae [lung problems], transaminitis [probably liver damage, probably from alcohol] and hemolytic anemia [too few red blood cells which carry oxygen in our blood].

"[The] Dermatology [department] was consulted, who ultimately determined that the skin findings represented zinc deficiency dermatitis and recommended oral zinc therapy. The rash demonstrated significant improvement over the next two days and was mostly clear by the third day of zinc treatment. The patient also reported improvements in her confusion and could remember details of her past medical history that she previously was unable to provide.”

About zinc deficiency:
  • cases of zinc deficiency in developed nations, such as the United States, are currently estimated to occur in 3–10% of the population
  • often occurs cases of anorexia nervosa, celiac disease, and other conditions of malnutrition
  • The symptoms [skin rash] represent a contact dermatitis that develops after normal contact with sweat, feces, and other irritants, due to poor defense and inadequate healing response.

Typical symptoms of zinc deficiency:
  • skin rash
  • depression and other mental health issues

“In conclusion, this case demonstrates the necessity of considering zinc deficiency in the differential diagnosis of any patient who presents with a constellation of rash, diarrhea, alopecia, and mood or mental status changes.”

Kelly S, Stelzer J W, Esplin N, et al. (September 08, 2017) Acquired Acrodermatitis Enteropathica: A Case Study. Cureus 9(9): e1667. DOI 10.7759/cureus.1667