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Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 61-63

A case of alcohol-dependent syndrome and pellagra

Department of Dermatology, M.V.J. Medical College and Research Hospital, Hoskote, Bangalore, Karnataka, India

Date of Submission03-Apr-2012
Date of Acceptance27-May-2012
Date of Web Publication6-Feb-2013

Correspondence Address:
Ambika Hariharasubramony
MVJMC and RH, B601, Sriram Shrishti Apartments, Sumangali Sevashram Road, Anand Nagar, Hebbal, Bangalore- 560 032
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0738.106997

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Pellagra was first described by Casal in 1735 as a disease due to the deficiency of niacin. Pellagra is more common in alcoholics. Chronic alcoholism and smoking are not uncommon in females of rural India. We report a case of a middle-aged female presenting with alcohol-dependent syndrome and pellagra.

Keywords: Pellagra, alcohol-dependent syndrome

How to cite this article:
Hariharasubramony A, Chankramath S, Prathyusha D. A case of alcohol-dependent syndrome and pellagra. Int J Nutr Pharmacol Neurol Dis 2013;3:61-3

How to cite this URL:
Hariharasubramony A, Chankramath S, Prathyusha D. A case of alcohol-dependent syndrome and pellagra. Int J Nutr Pharmacol Neurol Dis [serial online] 2013 [cited 2022 Aug 18];3:61-3. Available from:

   Case Report Top

A forty-year-old female, a manual laborer by occupation, presented with well-demarcated hyperpigmented dry scaly lesions with a burnt appearance on the dorsa of both hands extending to the forearms, since two months. Similar lesions were present on the dorsum of feet [Figure 1] and [Figure 2]. Pigmentation was present on the neck and malar area. She had anorexia, nausea, and intolerance to spicy food due to chelitis, glossitis, and erythema, and edema of buccal mucosa. Severe burning sensation of the feet had resulted in sleepless nights and fear of walking. She also complained of getting tired easily and of loss of interest in daily activities. She gave a past history of carcinoma of the cheek treated two years back with radiotherapy. There was no history of diarrhea or any neuropsychiatric symptoms, and no history of any systemic or local application of medications. She was moderately built and nourished, with mild pallor. She was a vegetarian and moderately built, well nourished, with mild pallor. Blood and urine investigations were within normal limits. Detailed evaluation revealed that psychological symptoms were of alcohol-dependent syndrome and neurological symptoms were due to alcoholic peripheral neuropathy. Skin biopsy showed hyperkeratosis, parakeratosis, increased melanin in the epidermis, and a few inflammatory infiltrates in the dermis, consistent with chronic lesions of pellagra [Figure 3]. She was treated with nicotinic acid 500 mg orally daily and multivitamin injections, and iron and protein, along with treatment for alcohol dependence. Skin and mucosal lesions started clearing and neuropsychiatric symptoms showed improvement in two weeks. She was referred to the cancer institute for follow-up of carcinoma of the cheek.
Figure 1: Pellagra lesions on hands

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Figure 2: Pellagra lesions on feet

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Figure 3: Hyperkeratosis and increased pigmentation in the basal layer ×10

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   Discussion Top

Pellagra is a chronic disease affecting the skin, nervous system, and gastrointestinal tract usually due to a deficiency of nicotinic acid (Niacin-vit B 3) or its precursor tryptophan. [1] Pellagra is now considered to be a multifactorial disease. [2] The deficiency of pyridoxine and thiamine which are required for the conversion of tryptophan to niacin and the deficiency of riboflavin and proteins also contribute to the symptoms of pellagra. Dietary deficiency of niacin occurs in people who eat polished rice, maize, corn, and jowar. However, the commonest cause of pellagra is alcoholism. [3] Poor diet, malabsorption of pyridoxine, and thiamine deficiency in alcoholism contribute to it. A staple diet of maize and corn contribute to pellagra as niacin is in a bound form in these cereals. In jowar, niacin is unbound but large quantities of leucine interfere with the conversion of tryptophan to niacin. Dietary deficiency of niacin can occur in anorexia nervosa, [4] food faddism, and malabsorption syndromes, and Hartnup disease, [5] In carcinoid syndrome, deficiency occurs due to the excessive conversion of tryptophan to serotonin. [6] Common drugs causing pellagra are isoniazid (INH), pyrazinamide, [5] fluorouracil, [6] mercaptopurine azathioprine, [7] and anticonvulsants.

The characteristically described three Ds of pellagra, diarrhea, dementia, and dermatitis are not present in all cases. Skin lesions are classic, characterized by photosensitive eruption, [8] symmetrically distributed on dorsum of hands, forearms, and sometimes feet. Lesions are well demarcated; skin has a sunburnt appearance with blister formation in the acute phase called wet pellagra, and in the chronic stage, it is pigmented, dry, glassy, and parchment like. Similar lesions around the neck forms the characteristic Casal necklace. Seborrhoeic dermatitis-like lesions on the nose are characterized by erythema and yellow scales on follicular orifices called sulfur flakes. Anorexia, nausea, and diarrhea are the main gastrointestinal complaints. Chelitis, stomatitis, red bald tongue, and ulcerations can occur in the oral mucosa. The mucosa of the vaginal and perianal regions can be affected. [1] Insomnia, apathy, dementia, encephalopathic syndrome, and coma may result in later stages. Neurological symptoms are due to concurrent peripheral neuropathy due to deficiency of other B complex vitamins. [1] Photosensitive skin lesions are due to the deficiency of urocanic acid which acts as an ultraviolet filter. [1],[8] In pellagra, nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP) levels are inadequate to maintain cellular energy transfer reactions. Tissues with a requirement of high energy like the brain and those with a high turnover of cells like the gastrointestinal tract and skin are particularly affected. [9] In acute cases, histopathology of the skin shows intraepidermal cell vacuolization and pallor of the upper epidermis with degeneration of the basal layer and intra or subepidermal blisters. In chronic cases, there may be hyperkeratosis, parakeratosis, irregular acanthosis of the epidermis and perivascular infiltrate in the dermis. [10] Measurement of urinary metabolites niacin and ratio of N-methyl pyridone and N-methyl niacinamide should be less than 2 for diagnosis [Figure 4]. Typical skin lesions and response to niacin, neurological symptoms improving within days, and skin lesions improving over a week are often diagnostic of pellagra. Kava dermopathy [11] is a pellagra-like dermatosis seen in Pacific islanders due to the consumption of the psychoactive beverage, kava, prepared from the dried roots of Piper methysticum. Deficiencies of folic acid and vitamin B12 are reported to be associated with an increased risk of colorectal cancer. [12] As manifestations of pellagra are due to deficiencies of multiple vitamins like folic acid and vitamin B12 apart from niacin, necessary investigations are mandatory to detect early cancer of the colon.
Figure 4: Vacoulization of cells in the epidermis ×40

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   References Top

1.Wan P, Moat S, Anstey A. Pellagra: A review with emphasis on photosensitivity. Br J Dermatol 2011;164:1188-200.  Back to cited text no. 1
2.Smith B, Curtis A, Parsons A, Yosipovitch G, Sangüeza OP. A 41-year-old woman with a scaly erythematous plaque admixed with erosions on the groin, back, and legs: Challenge. Nutritional deficiency. Am J Dermatopathol 2010;32:828, 850.  Back to cited text no. 2
3.Chichakli H, Frosch PJ, Brinkmeier T. Symmetrical bullous acral erythema in a 58-year-old female alcoholic. Hautarzt 2006;57:1030-3.  Back to cited text no. 3
4.Sato M, Matsumura Y, Kojima A, Nakashima C, Katoh M, Kore-Eda S, et al. Pellagra-like erythema on sun-exposed skin of patients with anorexia nervosa. J Dermatol 2011;38:1037-40.  Back to cited text no. 4
5.Seyhan ME, Selimoðlu MA, Ertekin V, Fidanoðlu O, Altinkaynak S. Acrodermatitis enteropathica-like eruptions in a child with Hartnup disease. Pediatr Dermatol 2006;23:262-5.  Back to cited text no. 5
6.Reichmann O, Sobel JD. Vulvovaginal pellagra and lichen sclerosis complicating carcinoid syndrome. Obstet Gynecol 2009;113:543-5.  Back to cited text no. 6
7.Oliveira A, Sanches M, Selores M. Azathioprine-induced pellagra. J Dermatol 2011;38:1035-7.  Back to cited text no. 7
8.Burnett CT, Lim HW. The photosensitive patient: Could it be pellagra? Br J Dermatol 2011;164:1178-9.  Back to cited text no. 8
9.Creeke PI, Dibari F, Cheung E, van den Briel T, Kyroussis E, Seal AJ. Whole blood NAD and NADP concentrations are not depressed in subjects with clinical pellagra. J Nutr 2007;137:2013-7.  Back to cited text no. 9
10.Miller SJ. Nutritional deficiency and the skin. J Am Acad Dermatol 1989;21:1-30.  Back to cited text no. 10
11.Norton SA, Ruze P. Kava dermopathy. J Am Acad Dermatol 1994;31:89- 97.  Back to cited text no. 11
12.Mostafa I Waly, Mostafa A Arafa, Sahar B Jriesat, Sunny A Sallam, Ahmed Al-Kafajei. Folate and vitamin B12 deficiency is associated with colorectal cancer in Jordan. Int J Nutr Pharm Neurol Dis 2012;2:57-60.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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