Peeling away from hypervitaminosis A: the importance of close monitoring in patients taking high dose vitamin A supplementation

Jessica A Eldredge, Noel E Cranswick and Kathleen H McGrath
Med J Aust 2022; 217 (11): . || doi: 10.5694/mja2.51776
Published online: 12 December 2022

A 14‐month‐old girl was noted to have exfoliation of her peripheries on day 19 after orthotopic liver transplant for end‐stage liver disease from extrahepatic biliary atresia. Initially peeling of the skin over her fingertips was seen. This progressed over one week to involve the interdigital spaces on her hands, palmar surfaces (Box, A and B) and feet (Box, C and D). There was no mucosal or genital involvement. Subtle irritability was reported by her parents, which was felt to be multifactorial given her prolonged hospital admission. There was no previous history of rash, vomiting or diarrhoea, and her post‐transplant recovery was otherwise uncomplicated. Her immunosuppression regimen included tacrolimus, azathioprine and prednisolone. Other regular medications included aspirin, amlodipine, omeprazole, trimethoprim with sulfamethoxazole, acyclovir, nystatin, zinc, and fat‐soluble vitamin replacement, as per local institutional transplant protocol. Blood tests revealed a vitamin A concentration of 3.5 μmol/L based on high performance liquid chromatography assay (range, 0.7–1.5 μmol/L). This was markedly increased from her pre‐transplant measurement of 0.5 μmol/L a month prior, when vitamin A supplementation had been increased.

  • 1 Royal Children's Hospital Melbourne, Melbourne, VIC
  • 2 University of Melbourne, Melbourne, VIC


Competing interests:

No relevant disclosures.

  • 1. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239‐245.
  • 2. Smith FR, Goodman DS. Vitamin A transport in human vitamin A toxicity. N Engl J Med 1976; 294: 805‐808.
  • 3. Nightingale S, Ng VL. Optimizing nutritional management in children with chronic liver disease. Pediatr Clin North Am 2009 Oct; 56: 1161‐1183.
  • 4. Pediatric and neonatal Lexi‐drugs: vitamin A [website]. Hudson (OH): Wolters Kluwer UpToDate, 2022. (viewed Apr 2022).
  • 5. Coghlan D, Cranswick NE. Complementary medicine and vitamin A toxicity in children. Med J Aust 2001; 175: 223‐224.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.