Pharmacist Insights: Signs of Vitamin C Deficiency

Vitamin C deficiency is typically linked to socioeconomic status and food access. The symptoms of vitamin C deficiency are frequently visible in individuals who develop scurvy. Symptoms such as a constellation of corkscrew hairs, perifollicular hemorrhage, and gingival bleeding are highly suggestive of vitamin C deficiency.

Vitamin C is typically depleted between 4 and 12 weeks if intake stops. Ascorbic acid can be affected by many factors that can impair absorption and functions. The best way to avoid becoming vitamin C deficient is to regularly consume fruits and vegetables.

Risk factors for vitamin C deficiency include:

• Alcoholism
• Babies only fed cow's milk
• Seniors only consuming tea and toast diet
• Not being able to afford fruits and vegetables
• Smoking
• Eating disorders
• Type 1 diabetes with high vitamin C requirements
• Disorders of the GI tract, such as inflammatory bowel disease.
• Iron overload that leads to wasting of vitamin C by the kidneys
• Restrictive diets and food allergies

Vitamin C deficiency shows symptomatically after 8 to 12 weeks of inadequate intake, presenting as irritability and anorexia. Following the initial symptoms, additional dermatologic symptoms include poor wound healing, gingival swelling with loss of teeth, mucocutaneous petechiae, ecchymosis, and hyperkeratosis.

Perifollicular hemorrhages are frequently localized to lower extremities because capillary fragility cannot withstand the gravity-dependent hydrostatic pressure, which can result in “woody edema.” Symptoms of the nails include koilonychia and splinter hemorrhages.

Rheumatologic problems can also occur, such as hemarthrosis and subperiosteal hemorrhage. This results from vascular fragility caused by impaired collagen formation.

Osseous pathology can also occur, presenting as fractures in brittle bones from the disrupted endochondral bone formation. Ocular manifestations of hemorrhage include flame hemorrhages, cotton-wool spots, and retrobulbar bleeding into optic nerves, which result in atrophy and papilledema. Later stages of the disease can be life-threatening with anasarca, hemolysis, jaundice, and convulsions.

For treatment, direct replacement of vitamin C is the standard therapy. This can include up to 300 mg daily for children and 500 mg to 1000 mg daily for adults. The endpoint of replacement therapy is 1 month or after resolution of clinical sequelae.

Alternative treatment options for adults include 1 to 2 g for up to 3 days followed by 500 mg daily for 1 week followed by 100 mg daily for up to 3 months. Patients should also be counseled on lifestyle modifications that ensure adequate intake. Patients should also be advised to limit their alcohol intake and to stop using tobacco.

Patients should also receive counseling on proper dietary habits, including foods rich in vitamin C, such as citrus fruits, berries, and certain kinds of melon. Vegetables high in vitamin C include spinach, red and green peppers, tomatoes, cabbage, cauliflower, broccoli, and Brussels sprouts. Patients can also be advised on appropriate vitamin C dietary supplementation.

If a patient’s symptoms do not improve within a few weeks, they should be referred to a specialist to determine the primary cause of deficiency. An interprofessional care team approach can lower the morbidity of vitamin C deficiency to improve patient outcomes.

Reference

Maxfield L, Crane JS. Vitamin C Deficiency. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493187/