What is Pellagra?

Pellagra is a systemic condition that results from a severe niacin (vitamin B3 or nicotinic acid) deficiency. A deficiency in tryptophan, which helps the body to process and use niacin, plays a role as well. The body might even be unable to use the available niacin, which can also result in the condition. Additionally, pellagra can occur if individuals do not have adequate tryptophan in their diets. This was once a major public health concern in the United States, but it is now exceedingly rare. It has, however, been reported in regions of the world where food is scarce.

There are two forms of pellagra — primary pellagra or secondary pellagra. In primary pellagra, efficiency results from a lack of niacin in the diet, while in secondary pellagra, niacin might be adequate but the body fails to process and use it. Secondary pellagra may occur due to factors like cirrhosis of the liver, eating disorders, alcoholism and anorexia. Primary pellagra mostly occurs in countries where corn is the staple food.

Pellagra may begin with subtle symptoms that are similar to those of other health conditions, but it can progress to very noticeable and life-threatening symptoms. It is usually identified by the four Ds — photosensitive dermatitis, diarrhea, dementia and death. Other symptoms include loss of appetite, mental confusion, weakness and abdominal pain.

One can prevent pellagra by taking niacin supplements and consuming a healthy diet with adequate calories. One can manage secondary pellagra by getting proper treatment for the underlying condition.

What is Niacin?

Niacin, or vitamin B3, is one of the eight B vitamins. It takes two main chemical forms, which have different effects on the body. Both forms can be present in foods and also in supplements. These forms are:

• Nicotinic acid: As a supplement, this is a form of niacin used to lower cholesterol levels and minimize the risk of heart disease.
• Niacinamide or nicotinamide: Unlike nicotinic acid, this form of niacin does not lower cholesterol levels. However, it helps to lower the risk of non-melanoma skin cancer as well as treat psoriasis.

Niacin cannot be stored in the body because it is water-soluble. The body may also excrete excess and unwanted amounts of the vitamin. The body can obtain niacin through consumed food, but it can also manufacture small amounts from the amino acid tryptophan.

Types of Pellagra

• Primary pellagra develops due to inadequate nicotinic acid (niacin) and tryptophan in the diet; compounds known as vital coenzymes. Generally, the body converts niacin into an amide, which assists in cellular function and metabolism. Niacin deficiency affects cellular functions in multiple tissues and organs.
• Secondary pellagra may be diagnosed when there is adequate niacin in the diet, but other factors and diseases may alter its absorption and processing like alcoholism and diarrhea.

Causes of Pellagra

The cause of pellagra depends on the type of pellagra. Individuals with primary pellagra suffer due to the cause of inadequate niacin or tryptophan in the diet. Its risk factors include malnutrition and poor diet. If you depend on corn as a staple food, the niacytin present in it is a form of niacin that humans cannot digest and absorb unless prepared properly. Corn is also a poor source of tryptophan.

Secondary pellagra will occur if certain problems prevent the absorption of niacin by the body. These problems may include alcoholism, certain medications such as immunosuppressive drugs and anticonvulsants, chronic diarrhea, cirrhosis of the liver, gastrointestinal diseases, carcinoid syndrome or anorexia, among others.

Symptoms of Pellagra

Dermatitis, dementia and diarrhea are the main symptoms associated with pellagra because a deficiency of niacin is highly noticeable in areas of the body where there are high rates of cell turnover, such as the skin or gastrointestinal tract. If untreated, it may result in a fourth D, which is death. Death normally occurs within four to five years if one does not receive immediate treatment.

Dermatitis caused by pellagra begins in the form of erythema (redness of the skin) with intermittent or acute onset. Acute dermatitis resembles sunburn in its initial stages.

Signs and symptoms of pellagra may include:

Gastrointestinal Issues

Gastrointestinal issues are particularly common symptoms of pellagra. These issues include:

• Indigestion
• Malnutrition
• Nausea and vomiting
• Poor appetite
• Diarrhea
• Belly pain
• Trouble eating or drinking
• Excessive salivation

Neurological Changes

Around 4-10 percent of individuals with chronic pellagra develop mental symptoms. In some cases, neurological signs of it appear early and may be difficult to identify. These symptoms include:

• Irritability
• Depression
• Confusion and disorientation
• Headache
• Tremors
• Delusions
• Memory loss
• Apathy

Skin Issues

The first sign of pellagra is reddened skin accompanied by superficial scaling in areas exposed to heat, sunlight and friction. This reddening is symmetrically distributed on the exposed areas. These are mainly the forearms and the back of the hands.

A rash that is symmetrical with a clear edge that sits between affected and unaffected skin also commonly occurs. It typically causes an itching or burning sensation. With time, the skin may become thick, hard and scaly. It can also be cracked and bleeding may occur, which later results in blackened crusts.

People with pellagra may notice lesion forming anywhere on their body, especially the arms, hands, lower legs, face, feet and neck. The tongue, gums and lips may be sore and start peeling. Dermatitis may also form around the neck — a symptom called Casal necklace.

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Diagnosing Pellagra

Pellagra may be tricky to diagnose due to the wide range of symptoms it causes. There is also no specific test to diagnose a niacin deficiency. However, urine tests may help to check if there is adequate niacin in the body. A blood test may also be necessary.

The health care provider may complete a physical exam that involves asking the patients about the foods they eat.

The doctor may also check the patient for any rashes, changes in mental state and gastrointestinal problems.

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In many cases, pellagra diagnoses aim at checking if the patient’s symptoms respond to niacin supplements.

Although uncommon, pellagra does occur in children. Younger patients may not show the typical symptoms associated with it, which makes diagnosis a bit tricky. Usually, children with pellagra may also be suffering from other nutritional deficiencies due to an underlying illness or socioeconomic circumstances.

Pellagra Treatment

The aim of pellagra treatment is to increase the body’s niacin level. The patients are mostly given niacin or nicotinamide supplements and dietary changes. The patients may also need to take other supplements.

Treating secondary pellagra mainly focuses on treating the underlying cause. A few cases of secondary pellagra have been shown to respond positively to taking nicotinamide (another form of vitamin B3) or niacin either intravenously or orally.

Symptoms of pellagra, such as skin sores, are usually treated. Skin improvement can, however, take several months. While recovering from any form of the condition, patients are advised to keep any rashes moisturized and away from sunscreen.

Supplements for Pellagra

Pure Vitamin B3 Niacinamide Capsules

As a dietary supplement, take one vitamin B3 capsule daily, preferably with a meal (since it increases the production of HCL, which aids digestion further). Niacinamide can be dangerous in larger servings. Do not exceed 1 gram unless advised by a physician.

Pure Vitamin B3 Niacinamide Powder

As a dietary supplement, take 100 mg (about 1/32 tsp) to 500 mg (about 3/16 tsp) of vitamin B3 powder daily, preferably with a meal. Again, avoid amounts exceeding 1 gram unless advised by a physician.

The Bottom Line

Pellagra refers to a deficiency in niacin. It is a rare condition in developed countries. It causes what is known as pellagra’s four Ds, which are its main symptoms — diarrhea, dermatitis, dementia and death, which all occur when the condition is not treated fast enough. Death due to pellagra occurs within four to five years. Most individuals experience a full cure if they receive immediate treatment.

In most cases, pellagra is treated with niacin or nicotinamide supplements. People with underlying conditions that cause pellagra require other treatment to help dissolve the deficiency. One can prevent the condition by making dietary changes that include a well-balanced and protein-rich diet. An individual with secondary pellagra may require treatment for the underlying condition causing niacin or tryptophan deficiency to prevent any future reoccurrence.