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

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.