Hemoglobin

international journal for hemoglobin research

ISSN: 0363-0269 (Print) 1532-432X (Online) Journal homepage: http://www.tandfonline.com/loi/ihem20

The Assessment of Skin Color and Iron Levels in

Pediatric Patients with β-Thalassemia Major Using
a Visual Skin Color Chart

Ibrahim H. Bucak, Habip Almis, Samet Benli & Mehmet Turgut

To cite this article: Ibrahim H. Bucak, Habip Almis, Samet Benli & Mehmet Turgut (2017): The
Assessment of Skin Color and Iron Levels in Pediatric Patients with β-Thalassemia Major Using a
Visual Skin Color Chart, Hemoglobin

To link to this article: http://dx.doi.org/10.1080/03630269.2017.1337033

Published online: 15 Jun 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ihem20

Download by: [Cornell University Library] Date: 15 June 2017, At: 05:41
HEMOGLOBIN, 2017
https://doi.org/10.1080/03630269.2017.1337033

ORIGINAL ARTICLE

The Assessment of Skin Color and Iron Levels in Pediatric Patients with
b-Thalassemia Major Using a Visual Skin Color Chart
Ibrahim H. Bucaka, Habip Almisa, Samet Benlia and Mehmet Turgutb
a
Department of Pediatrics, Adiyaman University School of Medicine, Adiyaman, Turkey; bDepartment of Pediatric Infectious Diseases,
Adiyaman University School of Medicine, Adiyaman, Turkey

ABSTRACT ARTICLE HISTORY

Patients with b-thalassemia major (b-TM), a disease that emerges due to disorder of hemoglobin (Hb) Received 29 March 2017
synthesis, require life-long erythrocyte transfusion. The purpose of this study was to evaluate skin color Revised 7 May 2017
and iron levels of patients with b-TM using a visual skin color chart. Each patient’s skin color was Accepted 7 May 2017
matched on a skin color chart under a fluorescent lamp by the same physician on each occasion. Iron,
iron binding capacity, ferritin and complete blood count (CBC) were studied for each patient enrolled. KEYWORDS
Colors marked on the visual skin color chart were compared with the laboratory results. Thirty-five b-Thalassemia (b-thal);
patients being monitored at our hospital were included, 19 (54.3%) males and 16 (45.7%) females. The children; ferritin; iron; skin
colors marked on the chart darkened as patients aged (p ¼ 0.002, r ¼ 0.49), the frequency of annual color
transfusions (p ¼ 0.022, r ¼ 0.385), ferritin levels (p < 0.001, r ¼ 0.72) and iron levels increased (p ¼ 0.001,
r ¼ 0.538) and as total iron binding capacity (TIBC) decreased (p < 0.001, r ¼ –0.709). On the basis of this
study, iron deposition in patients with b-TM was correlated with the colors on the chart.

Introduction
b-Thalassemia major (b-TM) is an autosomal recessive dis-
ease widely seen in the Mediterranean region, the Middle
East and Southwest Asia and characterized by a defect in the
hemoglobin (Hb) b-globin chain [1]. The most severe clin-
ical form of the disease is b-TM. A defect is present on two
b-globin genes that are necessary for normal Hb synthesis
[2]. Therefore, severe anemia develops in patients’ first
months of life. Patients diagnosed with b-TM require
erythrocyte transfusions at specific intervals [3]. Iron over-
load may occur in patients undergoing erythrocyte transfu-
sions. In addition, duodenal iron absorption also increases
due to impaired iron hemostasis in patients with b-TM [4].
Iron overload is the main cause of morbidity and mortality
in patients with b-TM [5,6]. Liver biopsy is the gold stan-
dard method for showing iron deposition, but due to its
invasive nature its use is limited [1]. In addition to this tech-
nique, other methods such as showing iron in the kidney,
liver and heart with magnetic resonance imaging (MRI),
determining iron expulsion in urine, examining blood fer-
ritin levels and non-transferrin bound iron (NTBI) are also
employed [7–10]. The most commonly used of these meth-
ods for monitoring iron levels is the measurement of blood
ferritin levels. However, since ferritin is an acute phase reac-
tant it is affected by several clinical conditions [8].
Human skin color is determined using a spectrophotom-
eter device, but since these are expensive they are not avail-
able in all clinics [11,12]. Patients with b-TM have a
darkened skin color due to iron overloading [2,3]. This study
evaluated the skin color and iron levels of pediatric patients
with b-TM using a visual skin color chart (VSCC), a non-
invasive technique.
Materials and methods
This prospective study involved 35 patients with b-TM being
regularly followed-up at a tertiary university hospital.
Approval for the study was obtained from the Biochemical
Research Ethical Committee (approval no. 2016/6-2).
Written consent was obtained from the parents of all
patients enrolled.
Demographic data (age and sex), the frequency of
erythrocyte transfusions in the previous year and iron chela-
tors use status were recorded for all patients. Patients pre-
senting for erythrocyte transfusion were examined by the
same physician before transfusion. A color was selected from
a VSCC (the Felix von Luschan skin color chart) by examin-
ing the abdominal skin (this being an area not exposed to
sunlight) under a fluorescent lamp in a room receiving no
sunlight (Figure 1) [11]. A number was recorded for the
color (from 1, the lightest, to 36, the darkest). Iron, iron
binding capacity, ferritin and complete blood count (CBC)
were investigated from venous blood before erythrocyte
transfusion for each patient enrolled. Iron and iron binding
capacity were studied using an Architect C8000 (Abbott
Laboratories, Abbott Park, IL, USA) device, ferritin on a DxI
600 (Beckman-Coulter Inc., Pasadena, CA, USA) device and

CONTACT Ibrahim H. Bucak ihbucak@hotmail.com Department of Pediatrics, Adiyaman University School of Medicine, Alt{nşehir Neighborhood, Uygur site,
G-Bloc No. 32, Adiyaman 02030, Turkey
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 I. H. BUCAK ET AL.
CBC on a Cell-Dyn Ruby (Abbott Laboratories) device, all
in accordance with the manufacturers’ instructions.
The Statistical Package for the Social Sciences (SPSS), ver-
sion 21.0 (IBM, Chicago, IL, USA) software was used for
statistical analysis of the data obtained. Descriptive data were
expressed as mean ± standard deviation (SD), minimum and
maximum. Spearman’s correlation analysis was used to com-
pare colors on the VSCC and parameters showing body
iron. A p value of <0.05 was considered to be significant.
Results
Thirty-five patients were included, 19 (54.3%) males and 16
(45.7%) females. The mean age of the patients was
111.7 ± 39.7 (48–180) months. All patients were using enteral
iron chelators. Mean frequency of erythrocyte transfusions in
the preceding 12 months was 14 ± 2.7 (10–18)/years. The
patients’ CBC results and iron, iron binding capacity and
ferritin values are shown in Table 1.
The lightest color number on the VSCC was 14 and the
darkest 26. Analysis of the distribution of colors marked on
the VSCC revealed one patient each with color numbers 13,
15, 16 and 17 (2.9%), two each with numbers 18, 19 and 22
(5.7%), three each with numbers 20 and 23 (8.6%), six with
numbers 24 and 26 (17.1%) and seven with number 25, the
most common (20.0%). Analysis of correlation between col-
ors marked on the VSCC and age, frequency of transfusion
Figure 1. The visual skin color chart (the Felix von Luschan skin color chart)
used in the study [10].
Table 1. Laboratory results of patients.
Parameters
WBC (109/L)
Hb (g/dL)
PCV (L/L)
MCV (fL)
MCH (pg)
MCHC (g/dL)
Platelets (109/L)
MPV (fL)
Iron (lg/dL)
Ferritin (ng/mL)
Total iron binding capacity (lg/dL)
WBC: white blood cell count; Hb: hemoglobin; PCV: packed cell volume; MCV: mean corpuscular volume; MCH: mean corpus-
cular Hb; MCHC: mean corpuscular Hb concentration; MPV: mean platelet volume.
a
The normal range for age was assessed for each patient [24].
and ferritin, iron and iron binding capacity revealed that col-
ors on the VSCC were darker, in other words, that numbers
were higher as patients aged (p ¼ 0.002, r ¼ 0.49), frequency
of transfusion in a year (p ¼ 0.022, r ¼ 0.385), ferritin values
(p < 0.001, r ¼ 0.72) and iron values (p ¼ 0.001, r ¼ 0.538)
increased and as total iron binding capacity decreased
(p < 0.001, r ¼ –0.709) (Figure 2).
Discussion
b-Thalassemia major is a b-globin chain synthesis defect
affecting 1.5% of the world population [3,13]. The condi-
tion results in anemia, and patients with b-TM require
repeated erythrocyte transfusions. If patients with b-TM do
not receive erythrocyte transfusions, they experience prob-
lems associated with anemia, while patients who receive
erythrocyte transfusions may experience various infections
transmitted with blood products (such as viral hepatitis and
bacterial infections), iron overloading, etc. [14,15].
The most hazardous condition for patients with b-TM is
iron overloading. Iron accumulates in two ways in patients
with b-TM. First, as hepcidin levels are low in these patients,
duodenal iron absorption increases. Second, iron deposition
occurs due to frequent erythrocyte transfusions [4,16].
Excess iron in the body accumulates in several organs,
including the liver, heart, kidney, pancreas and skin
[3,17,18]. Complications occur as a result, including heart
failure and arrhythmias, impairment of renal functions,
endocrine anomalies (such as hypoparathyroidism, hypothy-
roid, early puberty, short stature, vitamin D deficiency and
bone mineral density compromise) [3,6,13,18–20]. Iron che-
lation therapy is used to try to protect b-TM patients from
iron accumulation. Kitazawa et al. [21] stated that accumula-
tion of iron in the body protects against reactive oxygen spe-
cies and reported that patients with b-TM can be protected
against photoaging with iron chelation therapy.
Methods such as NTBI, blood ferritin level measurement,
liver biopsy, MRI of the kidney, liver and heart and deter-
mination of iron expulsion with urine are used in the fol-
low-up of iron overloading or chelation therapy follow-up
[1,3,6–10]. However, the use of these methods in follow-up
is problematic, since some are invasive (e.g. liver biopsy) and
some are not available in every center. In addition, MRI is
expensive and is not available in all hospitals.
Mean ± SD (min.–max.) Normal range
12.28 ± 6456.90 (4250.00–25.70) 3.70–10.00
6.92 ± 1.35 (5.00–10.00) see footnotea
0.21 ± 0.43 (0.14–0.30) see footnotea
69.70 ± 6.70 (58.00–84.00) 81.00–96.00
24.20 ± 3.42 (20.00–33.00) 27.00–31.20
31.50 ± 3.80 (24.00–38.00 31.80–35.40
300.90 ± 134.10 (124.00–550.00) 150.00–400.00
8.20 ± 1.20 (7.00–12.00) 6.90–10.60
181.10 ± 87.10 (75.00–496.00) 47.00–169.00
1159.60 ± 402.30 (330.00–1500.00) 23.90–336.20
82.00 ± 42.70 (40.00–185.00) 155.00–300.00

Figure 2. Correlations between age, number of annual transfusions, iron and ferritin levels and the visual skin color chart.
Dermatological studies have reported that several charts
can be used to evaluate skin color, and almost all of these
are used in assessing skin reactions and responses to derma-
tological/cosmetic treatments, in injuries and exposure to
ultraviolet light [22]. The VSCC used as a reference in this
study exhibits correlation with the evaluation of healthy skin
color using spectrophotometry (by assessing erythema and
melanin) [11]. Treesirichod et al. [11] proved that the VSCC
is a reliable skin color chart, but there is no skin color chart
specially prepared for b-TM patients. All references show
that iron accumulates in the skin, and the skin color of
patients with b-TM is known to darken [23]. However, the
qualitative degree of darkening in skin color has not been
compared with the quantitative amount of iron accumulation
in any previous study. Youssry et al. [23] showed that skin
iron levels (with skin biopsy and atomic absorption spectro-
photometry) were significantly correlated with hepatic iron
levels in patient with b-TM. Gorodetsky et al. [17] used
spectrometry to confirm high iron deposition in the skin of
patients with b-TM. Our study revealed significant findings
between the VSCC and the iron parameters of b-TM
patients. Patients’ skin colors in this study darkened as fer-
ritin (p < 0.001) and iron (p ¼ 0.001) levels increased. Skin
color was also proved to darken with age (p ¼ 0.002) and
frequency of yearly transfusions (p ¼ 0.022). Our review of
the literature revealed no previous studies using a VSCC to
HEMOGLOBIN 3
evaluate skin color and iron parameters in patients with
b-TM, and this study is therefore the first in this field.
Visual skin color chart is a method with high clinical
applicability. One limitation of the technique is that it is
dependent on the individual using the chart. Research is
now needed into whether or not the VSCC correlated with
other methods used to determine iron deposition, such as
cardiac involvement, particularly MRI, NTBI iron and iron
expulsion with urine.
This is the first study to evaluate the skin color and body
iron levels in patients with b-TM using a VSCC. It shows
that the colors matched on the VSCC darken as iron levels
increase in patients with b-TM. We need to find the simplest
and least invasive methods for the evaluation of iron level
parameters in b-TM patients.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
[1] Cao A, Galanello R. b-Thalassemia. Genet Med. 2010;12(2):
61–76.
[2] Makis A, Hatzimichael E, Papassotiriou I, et al. 2017 Clinical
trials update in new treatments of b-thalassemia. Am J
Hematol. 2016;91(11):1135–1145.
[3] Origa R. b-Thalassemia. Genet Med. 2017;19(6):609–619.
4 I. H. BUCAK ET AL.
[4] Tanno T, Bhanu NV, Oneal PA, et al. High levels of GDF15 in
thalassemia suppress expression of the iron regulatory protein
hepcidin. Nat Med. 2007;13(9):1096–1101.
[5] Hassan MA, Tolba OA. Iron chelation monotherapy in transfu-
sion-dependent b-thalassemia major patients: a comparative
study of deferasirox and deferoxamine. Electron Physician.
2016;8(5):2425–2431.
[6] Mokhtar GM, Gadallah M, El Sherif NH, et al. Morbidities and
mortality in transfusion-dependent b-thalassemia patients (sin-
gle-center experience). Pediatr Hematol Oncol. 2013;30(2):
93–103.
[7] Maggio A, Filosa A, Vitrano A, et al. Iron chelation therapy in
thalassemia major: a systematic review with meta-analyses of
1520 patients included on randomized clinical trials. Blood Cells
Mol Dis. 2011;47(3):166–175.
[8] Shamsian BS, Esfahani SA, Milani H, et al. Magnetic resonance
imaging in the evaluation of iron overload: a comparison of
MRI, echocardiography and serum ferritin level in patients with
b-thalassemia major. Clin Imaging. 2012;36(5):483–488.
[9] Hashemieh M, Azarkeivan A, Akhlaghpoor S, et al. T2-star
(T2) magnetic resonance imaging for assessment of kidney
iron overload in thalassemic patients. Arch Iran Med.
2012;15(2):91–94.
[10] Kontoghiorghes GJ. Iron mobilization from transferrin and
non-transferrin-bound-iron by deferiprone. Implications in the
treatment of thalassemia, anemia of chronic disease, cancer and
other conditions. Hemoglobin. 2006;30(2):183–200.
[11] Treesirichod A, Chansakulporn S, Wattanapan P. Correlation
between skin color evaluation by skin color scale chart and nar-
rowband reflectance spectrophotometer. Indian J Dermatol.
2014;59(4):339–342.
[12] Taylor S, Westerhof W, Im S, et al. Noninvasive techniques for
the evaluation of skin color. J Am Acad Dermatol.
2006;54(5Suppl2):S282–S290.
[13] Russo V, Rago A, Papa AA, et al. Electrocardiographic presenta-
tion, cardiac arrhythmias, and their management in
b-thalassemia major patients. Ann Noninvasive Electrocardiol.
2016;21(4):335–342.
[14] Cunningham MJ, Macklin EA, Neufeld EJ, et al. Thalassemia
Clinical Research Network. Complications of b-thalassemia
major in North America. Blood. 2004;104(1):34–39.
[15] Salama KM, Ibrahim OM, Kaddah AM, et al. Liver enzymes in
children with b-thalassemia major: correlation with iron over-
load and viral hepatitis. Open Access Maced J Med Sci.
2015;3(2):287–292.
[16] Pantopoulos K, Porwal SK, Tartakoff A, et al. Mechanisms of
mammalian iron homeostasis. Biochemistry. 2012;51(29):
5705–5724.
[17] Gorodetsky R, Goldfarb A, Dagan I, et al. Noninvasive analysis
of skin iron and zinc levels in b-thalassemia major and interme-
dia. J Lab Clin Med. 1985;105(1):44–51.
[18] Rasool M, Malik A, Jabbar U, et al. Effect of iron overload on
renal functions and oxidative stress in b thalassemia patients.
Saudi Med J. 2016;37(11):1239–1242.
[19] Ibrahim MH, Azab AA, Kamal NM, et al. Early detection of
myocardial dysfunction in poorly treated pediatric thalassemia
children and adolescents: two Saudi centers experience. Ann
Med Surg (Lond). 2016;9:6–11.
[20] Altincik A, Akin M. Prevalence of endocrinopathies in Turkish
children with b-thalassemia major: a single-center study.
J Pediatr Hematol Oncol. 2016;38(5):389–393.
[21] Kitazawa M, Iwasaki K, Sakamoto K. Iron chelators may help
prevent photoaging. J Cosmet Dermatol. 2006;5(3):210–217.
[22] Roberts WE. Skin type classification systems old and new.
Dermatol Clin. 2009;27(4):529–533.
[23] Youssry I, Mohsen NA, Shaker OG, et al. Skin iron concentra-
tion: a simple, highly sensitive method for iron stores evaluation
in thalassemia patients. Hemoglobin. 2007;31(3):357–365.
[24] Lerner NBC. The anemias. In: Kliegman RM, Stanton BF,
St. Geme JW, et al., editors. Nelson textbook of pediatrics.
Chap. 441, 19th ed. Philadelphia (PA): Elsevier/Saunders; 2011.