Diagnostic dilemma of flaky paint dermatitis versus acquired acrodermatitis enteropathica in a person presenting with generalized dermatitis, diarrhoea, and reduced level of consciousness

Differentiating Flaky Paint Dermatitis (FPD) in Protein Energy Malnutrition (PEM) from skin manifestations of Acquired Acrodermatitis Enteropathica (AAE) imposes a challenge due to overlapping clinical manifestations. This case study is on a 76-year-old presenting with reduced level of consciousness, generalized body oedema, and desquamating dermatitis with areas of hypopigmentation. His intake has reduced due to difficulty in swallowing, immobility, dependency for activities of daily living, and poor family support. This has led to severe malnutrition complicated with electrolyte imbalances, dehydration, and aspiration pneumonia. The hypothetico-deductive approach led to two main differential diagnoses in the forms of PEM and AAE.  Following stabilization with correction of dehydration and imaging to exclude other causes, the nutritional plan was gradually implemented. Energy and protein delivery were increased under thiamine cover due to the high risk of refeeding while correcting the electrolyte imbalances. One recommended daily allowance (RDA) of vitamins and minerals was administered through a multivitamin and mineral syrup. Supportive measures were also given, preventing hypothermia, hypoglycemia, and application of aqueous cream, betamethasone with soframycin for skin lesions. 
Even though the oedema settled with time, skin manifestations did not respond as expected with PEM treatment. There was rapid clinical improvement with the addition of a higher dose of zinc therapy (in the form of ZnSO4 1mg/kg), suggesting underlying zinc deficiency. This case study highlights the diagnostic challenge between AAE and FPD in PEM, particularly in resource-limited settings where clinicians should maintain a high index of suspicion for multiple nutritional deficiencies not only in children, but also in adults presenting with severe dermatitis and malnutrition.