Anorexia nervosa (AN) is a serious eating disorder characterized by persistent restriction of food intake, intense fear of gaining weight, and a distorted body image. Severe malnutrition forces the body to conserve energy, leading to a cascade of physical effects. These effects are often visibly apparent, causing recognizable changes to a person’s appearance, particularly in the face.
Defining the Visual Characteristics
The face of a person struggling with severe AN often presents a stark visual contrast between extreme thinness and specific areas of puffiness. A distinctive sign is the hollowing of the cheeks, which results from the body metabolizing the last remaining fat stores, including the buccal fat pads. This depletion also causes the eyes to appear sunken and tired, often framed by dark circles.
The skin’s appearance changes significantly under nutritional duress, often becoming pale, dry, and brittle (xerosis). To conserve warmth due to the absence of insulating body fat, the body may develop a fine, downy layer of hair called lanugo. This soft, often unpigmented hair can be noticeable on the cheeks, jawline, and neck.
Underlying Physiological Mechanisms
The profound changes in facial structure are direct consequences of the body’s starvation response and metabolic shifts. The severe lack of calories forces the body to break down subcutaneous fat tissue for fuel. This breakdown is particularly noticeable in the cheeks, where the buccal fat pads quickly diminish, leading to a gaunt, hollowed appearance.
Fluid and electrolyte imbalances caused by chronic restriction or purging are another key mechanism. Dehydration can reduce skin turgor, contributing to the sunken appearance around the eyes. Conversely, some individuals experience swelling (edema), often visible as puffiness, resulting from low blood protein levels (albumin) that allow fluid to leak into surrounding tissues.
A feature that dramatically alters the facial profile is the enlargement of the parotid glands, known as sialadenosis. These salivary glands, located just in front of the ears and behind the jawline, can swell due to repeated self-induced vomiting or severe calorie restriction. This glandular swelling creates an unusual contrast, making the lower face and jaw area appear rounded or puffy despite severe emaciation.
Distinguishing Features from Other Conditions
The combination of extreme emaciation and localized swelling helps distinguish AN facial changes from simple rapid weight loss. While significant weight loss causes hollowing, the glandular swelling of the parotids is a unique marker, especially when associated with compensatory behaviors. This swelling can make the face appear disproportionately full around the jaw, unlike the uniformly thinned look of general weight loss.
It is important to differentiate the AN face from Cushing’s Syndrome, which is characterized by a “moon face” and central obesity due to prolonged high cortisol levels. Although AN also causes elevated cortisol, the facial changes are fundamentally different. Cushing’s syndrome involves fat redistribution and accumulation, whereas AN involves systemic loss of fat, with any puffiness resulting from edema or glandular swelling.
Appearance Changes During Recovery
As an individual begins nutritional rehabilitation, the facial appearance undergoes a complex evolution that can be psychologically challenging. A common initial development is refeeding edema, where the face temporarily swells as the body corrects fluid and electrolyte imbalances. This transient puffiness is a sign of metabolic normalization, typically resolving within days to a few weeks.
The fine, downy lanugo hair will gradually disappear as the body restores healthy fat stores and internal temperature regulation normalizes. The parotid gland swelling is often the most persistent facial feature and may temporarily worsen at the start of refeeding before it subsides. Full resolution often takes longer than other changes, but continued nutritional stability is necessary for the face to return to its healthy, pre-illness appearance.