A 24-year-old woman with anxiety disorder and amenorrhea was referred by her therapist for examination. She reported exercising several hours a day, eating a diet of predominantly vegetables, and taking laxatives up to four times daily. She had a BMI of 21, anicteric sclera, yellowing of the skin, and brittle hair. Laboratory workup included low estradiol but normal thyroid, liver, and renal labs. She was diagnosed with anorexia nervosa with carotenoderma.

Carotenoderma is a yellowing of the skin due to excess circulating carotenoids in the blood. Carotenoids are a normal part of our diet. They contribute to skin color and act as antioxidants and free-radical scavengers. Primary carotenoderma comes from an excess of foods high in B-carotene such as carrots, sweet potatoes, cantaloupe, and other yellow, orange, or green fruits and vegetables. In anorexia nervosa, carotenoderma is hypothesized to be caused by deposition of carotenoids in the skin and retina due to a decreased availability of adipose tissue to store them. This finding can be used to diagnose anorexia nervosa in the right clinical setting—including when the BMI is in the “normal” range. It can also be seen in liver disease, nephrotic syndrome, hypothyroidism, and diabetes mellitus Figure 1.