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scurvy perifollicular hemorrhage corkscrew hairs clinical photograph

Clinical photograph consisting of two panels (a and b) demonstrating dermatologic and musculoskeletal signs of vitamin C deficiency (scurvy). Panel a shows the anterior forearm with a faint, erythematous perifollicular rash characterized by small, reddish macules centered around hair follicles. Panel b displays the bilateral lower extremities, exhibiting a more prominent and diffuse perifollicular petechial rash extending from the thighs to the lower legs. Significant bilateral knee swelling (effusions) is visible, along with small, horizontal, linear scars on the anterior knees consistent with healed biopsy incisions. The skin findings illustrate classic hemorrhagic manifestations of scurvy, where capillary fragility leads to perifollicular hemorrhage. This visual evidence is used in medical education to identify nutritional deficiencies in patients with restrictive eating habits, highlighting the triad of perifollicular petechiae, corkscrew hairs (as described in clinical context), and joint swelling due to hemarthrosis or effusions.

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PMID: 39296506

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Scurvy: clinical overview

Scurvy is the clinical syndrome caused by severe, prolonged vitamin C (ascorbic acid) deficiency. It is uncommon but remains important because it is often missed and can mimic vasculitis, bleeding disorders, infection, rheumatologic disease, or non-accidental injury in children.

Why vitamin C deficiency causes these findings

Vitamin C is required for hydroxylation of proline and lysine during collagen formation. Without it, collagen is poorly stabilized and connective tissue, capillaries, skin, gums, bone matrix, and wound tissue become fragile.

Other relevant roles include:

Enhanced absorption of non-heme iron
Carnitine synthesis, contributing to energy metabolism
Conversion of dopamine to norepinephrine
Antioxidant activity

The clinical result is capillary fragility, bleeding, impaired wound repair, gingival disease, musculoskeletal pain, and anemia.

Who is at risk?

Ask directly about dietary intake and functional barriers to eating. Important groups include:

Restrictive diets, food selectivity, avoidant/restrictive food intake disorder, autism spectrum disorder
Alcohol use disorder
Older adults, poverty, homelessness, social isolation, institutionalization
Anorexia nervosa or other eating disorders
Infants fed unsupplemented cow's milk or diets lacking fruits and vegetables
Malabsorption or very limited intake due to inflammatory bowel disease, chronic gastrointestinal disease, or bariatric surgery
Dialysis patients
Smokers, pregnancy, lactation, severe infection, trauma, and other states with increased vitamin C requirements
Patients with multiple micronutrient deficiencies

A recent systematic review highlights the association of scurvy with anorexia nervosa and the diagnostic overlap with psychiatric, gastrointestinal, and skin manifestations. Review indexed in PubMed.

Clinical features

The classic teaching is the four H's:

Hemorrhagic manifestations
Follicular hyperkeratosis
Hypochondriacal or mood symptoms such as irritability/depression
Hematologic abnormalities, especially anemia

Early, nonspecific symptoms

Fatigue, weakness, lethargy
Malaise, irritability, low mood
Myalgia and diffuse limb pain
Poor appetite or weight loss
Delayed wound healing

Characteristic skin and hair signs

Perifollicular petechiae or hemorrhages, especially on the legs
Purpura and ecchymoses, often extensive over lower limbs
Corkscrew hairs: coiled, twisted hairs caused by abnormal follicular keratinization
Follicular hyperkeratosis or keratotic plugs
Poor healing wounds
Woody edema, sometimes resembling cellulitis

Clinical features of scurvy: perifollicular petechiae on the forearm and lower extremities with knee swelling

Oral findings

Swollen, spongy, painful gums
Gingival bleeding, often around teeth
Gingival hypertrophy
Loose teeth, halitosis, tooth loss in advanced disease

Gingivitis can be absent in people who are edentulous or have excellent oral hygiene. Andrews' Diseases of the Skin: Clinical Dermatology, p. 556.

Musculoskeletal findings

Bone pain and tenderness
Arthralgia, joint swelling, hemarthrosis
Intramuscular and subperiosteal hemorrhage
Refusal to walk or apparent pseudoparalysis in children
Fractures may occur in severe pediatric disease

Other manifestations

Epistaxis, subconjunctival hemorrhage, subungual hemorrhage
Gastrointestinal, pericardial, peritoneal, adrenal, or intracranial bleeding in severe cases
Anemia, often multifactorial: iron deficiency, blood loss, poor diet, and coexistent folate or B12 deficiency
Increased susceptibility to infection may occur in severe malnutrition

Diagnosis

Scurvy is primarily a clinical diagnosis. The combination of dietary risk plus perifollicular hemorrhage, corkscrew hairs, gingival bleeding, bruising, bone pain, or poor wound healing should trigger suspicion.

History

Ask specifically about:

Actual foods consumed over the previous 1 to 3 months
Fruits, vegetables, fortified drinks, and supplements
Food restriction, sensory aversion, dysphagia, vomiting, alcohol use, inability to shop/cook
Renal replacement therapy, malabsorption, and other nutritional deficiencies
Drug history and anticoagulant use

Examination

Look for:

Perifollicular petechiae on legs, buttocks, forearms
Corkscrew hairs and follicular keratosis
Gum bleeding and swelling
Bruising or deep soft-tissue hematoma
Joint pain/swelling and reluctance to bear weight
Signs of other nutrient deficiencies

Laboratory tests

Obtain blood before supplementation or major dietary changes, if feasible, because plasma vitamin C rises quickly after repletion.

Useful tests:

Plasma/serum ascorbic acid: low level supports deficiency, but reflects recent intake.
Leukocyte vitamin C: may better reflect body stores where available.
CBC with indices and reticulocyte count
Ferritin, iron studies
Folate, vitamin B12, vitamin D, zinc, albumin or other nutrition-focused tests as clinically indicated
PT/INR and aPTT if bleeding is substantial or the diagnosis remains uncertain
CRP/ESR if vasculitis, infection, or inflammatory disease remains a concern

A prompt clinical response to vitamin C supports the diagnosis. Andrews' Diseases of the Skin: Clinical Dermatology, p. 556.

Histology

Skin biopsy is rarely needed. If done, it may show:

Perifollicular hemorrhage
Follicular hyperkeratosis
Coiled hairs
Little or no true vasculitic inflammation

This helps distinguish scurvy from leukocytoclastic vasculitis.

Imaging in children

Radiographs are useful when a child has limb pain, refusal to walk, swelling, or suspected subperiosteal bleeding.

Typical radiographic features:

Generalized osteopenia
Dense metaphyseal line: Frankel white line
Metaphyseal lucent band
Metaphyseal spurs: Pelkan spurs
Epiphyseal ring or “pencil” outline: Wimberger sign
Periosteal reaction from recurrent subperiosteal hemorrhage

Scurvy in infancy often presents between 6 and 9 months, with defective osteoid production and impaired endochondral ossification. Grainger & Allison's Diagnostic Radiology, p. 1466.

Differential diagnosis

Condition	Clues favoring it over scurvy
Leukocytoclastic vasculitis / IgA vasculitis	Palpable purpura, renal or gastrointestinal involvement, inflammatory biopsy
Thrombocytopenia	Markedly low platelet count, widespread petechiae without corkscrew hairs
Coagulation disorder	Abnormal PT/INR or aPTT, hemarthrosis pattern depending on cause
Leukemia	Cytopenias, blasts, systemic symptoms, abnormal marrow evaluation
Child abuse	Inconsistent history or injury pattern, but scurvy must not be overlooked in nutritionally vulnerable children
Osteomyelitis / septic arthritis	Fever, focal infection signs, raised inflammatory markers, imaging/culture findings
Rickets	Different biochemical and radiographic pattern, though coexisting malnutrition can occur
Ehlers-Danlos syndrome	Lifelong hypermobility/skin hyperextensibility rather than dietary history and rapid response to vitamin C

Treatment

1. Start vitamin C replacement promptly

In a clinically suspected case, treatment should not be delayed for laboratory confirmation if the patient is unwell.

Reasonable commonly used adult regimens include:

Ascorbic acid 200 mg orally daily, with clinical improvement often beginning within days, or
1,000 mg orally daily for several days to 1 week, followed by 100 mg daily as maintenance during nutritional rehabilitation.

The exact regimen varies by reference and patient factors. The priority is reliable repletion plus correction of the dietary cause. Andrews' Diseases of the Skin: Clinical Dermatology, p. 556.

For children, dosing should be prescribed according to age, weight, severity, oral tolerance, and local pediatric guidance. In severely ill patients, those unable to take oral treatment, or those with major bleeding, seek urgent pediatric or medical specialist input.

2. Treat associated deficiencies and complications

Evaluate and correct iron, folate, B12, vitamin D, zinc, and protein-calorie malnutrition as appropriate.
Manage significant anemia, hematoma, hemarthrosis, or suspected occult bleeding.
Provide analgesia and mobility support for bone/joint pain.
Address dental disease.
In severe malnutrition, assess risk for refeeding syndrome before rapid nutritional escalation.

3. Correct the underlying cause

Dietitian referral
Eating-disorder and mental-health treatment when relevant
Social work support for food access, housing, caregiving, or substance-use treatment
Feeding/occupational therapy for sensory food restriction or neurodevelopmental conditions
Dialysis-specific nutritional planning where relevant

Expected response

Constitutional symptoms may improve within days.
Gum bleeding, petechiae, bruising, and pain usually improve over days to a few weeks.
Hair/skin changes and anemia may take longer.
Failure to improve should prompt reassessment for an alternative diagnosis, nonadherence, malabsorption, ongoing bleeding, or another nutritional deficit.

Prevention and dietary advice

Good vitamin C sources:

Citrus fruits, guava, kiwi, berries
Tomatoes, peppers
Broccoli, cabbage, leafy vegetables
Potatoes

The adult recommended intake is roughly 90 mg/day for men and 75 mg/day for women, with higher needs in smokers. Vitamin C is water-soluble and heat-sensitive, so prolonged storage and cooking can reduce content.

Clinical red flags requiring urgent assessment

Urgent evaluation is appropriate for:

Major bleeding, severe anemia, syncope, dyspnea, or chest pain
Severe limb pain, inability to walk, suspected fracture, or joint bleeding
Fever or concern for septic arthritis/osteomyelitis
Neurologic symptoms or concern for intracranial hemorrhage
A malnourished child with bruising, bone pain, or refusal to bear weight
Significant eating-disorder malnutrition or risk of refeeding syndrome

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