Dermatology | Metabolism

Carotenemia

Background

1. Definition
   • Yellow pigmentation of skin associated with increased blood carotene levels (View image)
     • In most cases associated with large consumption of dietary carotene
   • Also known as Hypercarotenemia
2. Synopsis
   • Benign condition
   • Confused with jaundice, may lead to unnecessary diagnostic workup
   • First described in 1919 by Hess and Meyers
   • Reported cases during WWI and WWII
     • Whereby a lot of people mostly consumed a plant-based diet
       • Due to food shortages and famine

Pathophysiology

1. Etiology
   • Increased dietary content
     • Carotene is found in all pigmented fruits and vegetables
     • The content may be masked by presence of chlorophyll
     • Ripening increases foods content of carotene
     • Homogenizing the food will increase the availability of carotene compared to pureeing
   • Carotenemia is rare in other conditions but has been found with
     • Hypothyroidism
     • DM
     • Anorexia nervosa
     • Liver disease
     • Renal disease
     • Familial
2. Risk Factors/Predisposition
   • Excessive ingestion of carotenoids (>30 mg/day) for prolonged period of time
   • Carotene-rich foods:
     • Breast milk
     • Milk
     • Butter
     • Palm oil
     • Fruits
       • Apricot
       • Cantaloupe
       • Mango
       • Orange
       • Papaya
       • Peaches
       • Prunes
     • Vegetables
       • Carrots
       • Green beans
       • Asparagus
       • Broccoli
       • Cucumber
       • Lettuce
       • Parsley
       • Spinach
       • Squash
       • Mustard
       • Pumpkins
       • Kale
       • Sweet potatoes
     • Corn
     • Egg yolks
3. Pathology
   • Carotene is excreted in stool, skin, and urine
     • Carotene is excreted by sebaceous glands and in sweat
   • Derived from plants
   • Chief precursor of Vitamin A
     • Converted to Vitamin A in mucosal cells of small intestine
   • Absorption enhanced by increased fiber content of plant and smaller particular size of food
   • Cooking, mashing, and pureeing make carotene more available for absorption
   • Serum carotene levels are a good index of fat digestion and absorption
4. Epidemiology
   • Morbidity/Mortality
     • None
   • Incidence/ Prevalence
     • 22% prevalence of carotenemia in children w/ mental disabilities (according to one study)
     • 2% prevalence among 615 children on a high carotenoid-containing diet (Sri Lankan study)
     • Glasgow study
       • Median age at presentation: 13 months (range 7 months to 11 years)

Diagnostics

1. History/Symptoms
   • Age-Related
     • Most often recognized in toddler and younger age group
     • Median age at diagnosis 13 months (range 7 mo-11 yo)
2. Physical Exam/Signs
   • Yellow skin pigmentation is enhanced by artificial light
   • Greatest concentration is in areas with increased sweating
     • Palms
     • Soles
     • Nasolabial folds
   • Sclera and mucous membranes are spared
   • Variation of yellow pigmentation between individuals with equal amounts of carotene in their diet
3. Labs/Tests
   • Elevated serum carotene levels
4. Differential Diagnosis
   • Jaundice
   • Lycopenemia
     • Orange-red discoloration
     • Associated with excessive intake of lycopene
       • Found in tomatoes and beets
     • Benign condition
   • Vitamin A and toxicity
     • Vitamin A toxicity associated with
       • Alopecia
       • Rashes and pruritus
       • Anorexia
       • Increased intracranial pressure
       • Weight loss

Treatment

1. Initial/Prep/Goals
   • Rule out jaundice
   • No treatment necessary
   • Decrease intake of high carotene containing foods
   • Consultation w/ dietician is helpful in some cases
2. Complications
   • Toxic retinopathy
     • Due to excess canthaxanthin (toxic carotenoid metabolite)
     • Changes are reversible
     • No long-term sequelae
   • Vitamin A poisoning (very rare)
     • Constipation
     • Hypercarotenemia
     • Increased LFTs

Disposition

1. Admission Criteria
   • Not required
2. Consult(s)
   • Nutritionist as needed
3. Discharge/Follow-up instructions
   • Benign and harmless
     • Can discharge home with patient education

1. Reassure parents carotenemia is a benign condition that requires no treatment
2. If extreme parental anxiety is present
   • Educate parents which foods are rich in carotene
   • Place child on a carotene-deficient diet
     • Serum carotene levels should drop sharply within a week
     • Yellow discoloration of skin gradually disappears over weeks-months
     • Medications not indicated for the treatment of diet-induced carotenemia
   • Inform parents many green vegetables are rich in carotene (e.g., green beans, spinach)

References

1. Karthik SV, Campbell-Davidson D, Isherwood D. Carotenemia in infancy and its association with prevalent feeding practices. Pediatr Dermatol. Nov-Dec 2006;23(6):571-573
2. Sale TA, Stratman E. Carotenemia associated with green bean ingestion. Pediatr Dermatol. Nov-Dec 2004;21(6):657-659
3. Sansone RA, Sansone LA. Carrot man: A case of excessive beta-carotene ingestion. Int J Eat Disord. Sep 2012;45(6):816-818
4. Leung, Alexander. Carotenemia. Advances in Pediatrics. 34: 223-248. 1987
5. McGowan R, Beattie J, Galloway P. Carotenaemia in children is common and benign: most can stay at home. Scott Med J. 2004 Aug;49(3):82-4.
6. Carotenemia. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK534878/. [Accessed November 2023]

Contributor(s)

1. Ballarin, Daniel, MD

Updated/Reviewed: November 2023