What is the treatment for pellagra?

Treatment of Pellagra

The treatment of pellagra consists of nicotinamide 100 mg three times daily for 3 weeks, with the total daily dose not exceeding 600 mg. 1

Diagnosis and Clinical Presentation

Pellagra is diagnosed primarily through recognition of the classic "3D syndrome":

• Dermatitis: Bilaterally symmetrical erythema on sun-exposed areas (face, neck, dorsa of hands, chest)

  • Initially resembles sunburn, may progress to vesicles and bullae
  • Skin manifestations are crucial for diagnosis due to their specificity 2, 3

• Diarrhea: Chronic or recurrent, typically watery

  • May lead to malnutrition and cachexia
  • Sometimes bloody or mucoid 4

• Dementia: Neuropsychiatric manifestations including:

  • Photophobia, asthenia, depression, hallucinations
  • Confusion, memory loss, psychosis
  • If untreated, can progress to disorientation, stupor, and death 4

Treatment Protocol

1. Pharmacological Treatment:

   • First-line: Nicotinamide 100 mg three times daily for 3 weeks 1
   • Alternative: Nicotinic acid 15-20 mg/day 2
   • Include other B vitamins, zinc, and magnesium in treatment 2, 4

2. Nutritional Management:

   • Provide diet rich in calories and niacin sources:
     • Meat, poultry, fish, eggs, nuts, legumes, whole grains 2
   • Topical emollients for skin lesions to reduce discomfort 4
   • Consider parenteral or enteral nutrition with adequate niacin content in severe cases 2

3. Monitoring and Response:

   • Skin manifestations typically resolve within 24-48 hours after niacin administration 5
   • Neurological symptoms may take longer to resolve
   • Continue treatment until all symptoms resolve

High-Risk Populations

Maintain high index of suspicion in patients with:

• Malnutrition, especially corn-based diets lacking niacin
• Chronic alcoholism (35.24% of cases) 6
• Gastrointestinal malabsorptive conditions
• Medication use (isoniazid, 5-fluorouracil, etc.) (25.71% of cases) 6
• Homelessness with irregular eating patterns
• Carcinoid tumors
• Metabolic disorders 2
• Anorexia nervosa 5

Prevention

• Nutritional education about food sources of niacin
• Avoidance of alcohol
• Regular monitoring of at-risk populations
• Where diet is deficient in niacin, vitamin B complex tablets can be used to prevent pellagra 1
• In maize-eating populations, niacin-fortified flour should be included in the diet 1

Clinical Pitfalls to Avoid

• Failing to consider pellagra in patients with chronic diarrhea of unknown etiology 7
• Missing the diagnosis in developed countries where it's now rare but still exists 3
• Not recognizing partial presentations (not all patients present with the complete triad)
• Overlooking pellagra in patients with alcoholism or on certain medications
• Delaying treatment, which can lead to progression to death if untreated

Maintaining a high index of suspicion and prompt treatment with nicotinamide or nicotinic acid is essential for this potentially fatal but readily treatable condition.