Nicotinamide in Dermatology: Uses and Dosing
Nicotinamide (niacinamide) is most strongly indicated at 500 mg twice daily (1000 mg/day total) for prevention of actinic keratoses and keratinocyte carcinomas in high-risk immunocompetent patients, combined with comprehensive sun protection measures. 1, 2
Primary Indication: Skin Cancer Prevention
For patients with history of multiple keratinocyte carcinomas (basal cell or squamous cell carcinomas):
- Dose: 500 mg twice daily (1000 mg/day total) 1, 2, 3
- This dosing reduces actinic keratoses and keratinocyte carcinomas in high-risk patients 1
- The preventive effect is lost when treatment is discontinued, requiring continuous use 2
Critical exclusion: Nicotinamide is NOT effective in immunosuppressed organ transplant recipients (rate ratio 1.0; 95% CI, 0.8-1.3; P=0.96), who should instead receive systemic retinoids or capecitabine 2, 3
Secondary Dermatological Applications
Pemphigus vulgaris (milder cases):
- Nicotinamide combined with tetracycline can be considered as an adjuvant therapy 4
- Strength of recommendation: C; Quality of evidence: IV 4
- Typically used with tetracycline and/or prednisolone to achieve steroid-sparing effect 4
Other conditions with evidence (topical or oral):
- Acne vulgaris 5, 6, 7
- Rosacea 8, 6, 7
- Atopic dermatitis 5, 6, 7
- Melasma and hyperpigmentation 6, 9
- Autoimmune blistering disorders 7
Safety Profile and Side Effects
Nicotinamide has a favorable safety profile compared to nicotinic acid:
- No flushing occurs with nicotinamide, unlike nicotinic acid which causes facial, arm, and chest flushing at doses as low as 30 mg 1, 3
- Upper safety limit: approximately 900 mg/day for adults per European Food Safety Authority, though 1000 mg/day has proven safe in clinical trials 1, 2, 3
Common side effects (generally mild):
- Gastrointestinal symptoms: nausea, vomiting, diarrhea 1, 2, 3
- Flushing and headaches due to vasodilation (when combined with tetracyclines in pemphigus treatment) 4
Safe in cardiovascular disease:
- No known cardiovascular contraindications or adverse cardiac effects 2
- Specifically safe in patients with coronary artery disease, unlike celecoxib which carries significant cardiovascular risk 2
Practical Implementation Algorithm
Step 1: Confirm patient eligibility
- High-risk for keratinocyte carcinomas (history of multiple skin cancers or extensive actinic keratoses) 2
- Immunocompetent status (NOT organ transplant recipients on immunosuppression) 2, 3
- No contraindication to oral supplementation 10
Step 2: Initiate therapy
- Prescribe 500 mg twice daily 1, 2, 3
- Available as tablets; standard dosing is 1-2 tablets daily per FDA labeling 10
- Counsel that this is NOT a substitute for UV protection 2, 3
Step 3: Mandate concurrent sun protection
Step 4: Establish monitoring schedule
- Dermatology follow-up every 3-6 months for skin surveillance 2
- Annual skin cancer screening for all patients with history of keratinocyte cancers 2
Step 5: Manage expectations
- Preventive effect requires continuous use 2
- Mild digestive symptoms may occur but are generally well-tolerated 1, 2, 3
Storage and Administration
- Store at 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F) 10
- Take as directed by physician, typically 1-2 tablets daily 10
Key Clinical Pitfalls to Avoid
Do not use nicotinamide as monotherapy for skin cancer prevention - it must be combined with comprehensive sun protection measures, as it is not a substitute for UV protection 2, 3
Do not prescribe for immunosuppressed transplant recipients - these patients showed no benefit and require alternative strategies like systemic retinoids or capecitabine 2, 3
Do not confuse with nicotinic acid (niacin) - nicotinic acid has a much lower upper safety limit (10 mg/day for free nicotinic acid) and causes significant flushing, whereas nicotinamide is safe at 900-1000 mg/day without flushing 1
Do not discontinue sun protection measures - nicotinamide enhances but does not replace the need for SPF ≥15 sunscreen, protective clothing, and sun avoidance 2, 3