Table of ContentsView AllTable of ContentsThe Three D’s of PellagraCausesDiagnosisTreatment
Table of ContentsView All
View All
Table of Contents
The Three D’s of Pellagra
Causes
Diagnosis
Treatment
Pellagra is a condition that occurs when a person develops a deficiency in vitamin B3, also calledniacin. There are two types of deficiency a person can have. A primary deficiency occurs when a person is not getting enough niacin in their diet, and a secondary deficiency is when the body isn’t able to use the nutrient properly.
Pellagra shows up a collection of symptoms, commonly referred to as “the three D’s”: dementia, diarrhea, and dermatitis. While the condition can be cured if diagnosed, pellagra can be fatal if left untreated.
Verywell / Nusha Ashjaee
There are three common symptoms of pellagra referred to as the “three D’s.” Untreated pellagra will lead to death, sometimes called the “fourth D,” within a few years.
Diarrhea
In the early stages, pellagra symptoms may be vague. Patients with the condition may only have one or two of the “Ds” along with other nonspecific symptoms. The rash, however, is seen in the majority of cases.
Watery diarrheais usually the first symptom and is the result of inflammation of the gastrointestinal mucosa. As the condition progresses, people with pellagra may have no appetite (sometimes leading to anorexia), feel sick to their stomach (nauseated), or have stomach pain. These symptoms can cause a cycle where a person who is already malnourished does not feel well enough to eat.
Dermatitis
Dermatitis, or skin inflammation, typically appears in the form of a rash in sun-exposed areas of the body. In fact, it often looks like a sunburn. The rash may become more intense, with skin peeling and changes in skin color (pigmentation) that can be permanent.
As the rash begins to blister, the skin may become rough and scaly, especially on the bottom part of the hands and feet, as well as on the face (a pattern known as a butterfly or malar rash). Areas of affected skin may be itchy, painful, and sensitive to the sun.
This photo contains content that some people may find graphic or disturbing.See PhotoPellagra on neck.DermNet / CC BY-NC-ND
This photo contains content that some people may find graphic or disturbing.See Photo
This photo contains content that some people may find graphic or disturbing.
Dementia
The neurological signs and symptoms occur later when the deficiency has become severe and has been going on for a prolonged period of time. At first, a person may experience memory loss, trouble sleeping, and mood changes.
As the deficiency gets worse, the neurological symptoms can be severe: a person may become disoriented or not know where they are, begin to havehallucinations, or even be in a stupor, failing to respond to their surroundings.
In extreme cases, the neurological symptoms of pellagra appear dementia-like or even stroke-like.
As the condition worsens and body systems begin to shut down, other symptoms may develop, including:
Left untreated, pellagra can be fatal in three to five years.
What Causes Pellagra?
Primary and secondary pellagra have different underlying causes. Primary pellagra occurs when a person is low in niacin ortryptophan.
A person’s socioeconomic circumstances can also place them at risk for developing pellagra. People living in poverty who don’t have adequate access to nutritious food, those living in famine conditions, and refugees are more likely to become severely malnourished.
While pellagra mostly develops in adults, children who are living in countries experiencing famine, whose families are homeless, or who are being neglected may also be at risk.
Pellagra occurs equally in men and women. It primarily occurs in adults but in some cases, infants and children may be at risk. People of all races can develop pellagra, though it is seen more often in developing countries and poverty-stricken regions of developed nations.
Diagnosing Pellagra
If a healthcare provider suspects a person has pellagra, there are several ways to confirm the diagnosis. They will perform a physical exam and ask the person about diet and lifestyle.
Findings that support a clinical diagnosis of pellagra include the characteristic skin rash. Patients often report diarrhea or other gastrointestinal symptoms, including swollen tongue. In some cases, patients will have started to experience changes in their moods, sleeping habits, and cognition.
Pellagra is uncommon in children, but it does occur. Younger patients may not present with the typical symptoms of pellagra, however, which can make diagnosis tricky.
Usually, children who are found to have pellagra are also suffering from other nutritional deficiencies, either as a result of socioeconomic circumstances or an underlying illness.
To confirm the diagnosis of pellagra, doctors may want to take blood or urine samples to test for low levels of niacin. They may also be looking for other abnormalities, such as low tryptophan, NAD, and NADP levels. Tests can also help rule out other conditions that have similar symptoms.
If a person is found to have pellagra, the next step will be determining the cause. Sometimes, the answer will be fairly obvious, such as if someone reports eating a limited diet or is malnourished.
Other patients may need additional tests to determine the reason for the deficiency. These tests may include:
Diagnosing pellagra and figuring out what caused a person to develop the condition is very important. It can also cause a number of complications, including:
Untreated niacin deficiency can cause a person to go into a coma. After several years, the condition causes major damage to the internal organs, which is ultimately fatal.
How Is Pellagra Treated?
The main treatment for pellagra is nicotinamide, a water-soluble form of niacin, for 3–4 weeks. This form causes fewer side effects than regular niacin.
Treatment may also include other nutrients to aid in recovery.A high-calorie, nutritious diet with plenty of hydration is essential to helping the body heal and to prevent a recurrence of pellagra.
The first line of treatment for someone with pellagra is ensuring they have enough to eat, and that the diet they are eating is well-balanced and adequate in calories.
Treatment may also include addressing underlying problems such as chronic alcohol dependence.
Once a person is able to resume a diet of solid foods, they may work with a dietician ornutritionistto ensure they are getting plenty of niacin in their diet. Meat, dairy, and nuts are good sources of niacin, as are green, leafy vegetables.
People can also take a supplemental form of vitamin B3, especially if they are also deficient in other B vitamins (such as in the case of malabsorption) or are taking medications that affect how their body can use niacin. A healthcare provider can help a person decide what regimen they need.
13 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Prabhu D, Dawe RS, Mponda K.Pellagra a review exploring causes and mechanisms, including isoniazid‐induced pellagra.Photodermatol Photoimmunol Photomed. 2021;37(2):99-104. doi:10.1111/phpp.12659Mills K, Akintayo O, Egbosiuba L, et al.Chronic diarrhea in a drinker: a breakthrough case of pellagra in the US South.J Investig Med High Impact Case Rep. 2020;8:232470962094130. doi:10.1177/2324709620941305Narasimha VL, Ganesh S, Reddy S, et al.Pellagra and alcohol dependence syndrome: findings from a tertiary care addiction treatment centre in India.Alcohol Alcohol. 2019;54(2):148-151. doi:10.1093/alcalc/agz004Pinheiro H, Matos Bela M, Leal AF, Nogueira L, Mesquita M.Hidden hunger: a pellagra case report.Cureus. 2021 Apr 25;13(4):e14682. doi:10.7759/cureus.14682Madhyastha SP, Shetty GV, Shetty VM, Reddy CT.The classic pellagra dermatitis.BMJ Case Rep. 2020;13(10):e239741. doi:10.1136/bcr-2020-239741Bilgili SG, Karadag AS, Calka O, Altun F.Isoniazid-induced pellagra.Cutan Ocul Toxicol. 2011;30(4):317-319. doi:10.3109/15569527.2011.574303MedlinePlus.Hartnup disease. Updated August 18, 2020.Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O.Pellagra: a clinical, histopathological, and epidemiological study of 7 cases.Actas Dermosifiliogr. 2012;103(1):51-58. doi:10.1016/j.adengl.2011.05.003Gupta Y, Shah I.Ethionamide-induced pellagra.J Trop Pediatr. 2015;61(4):301-303. doi:10.1093/tropej/fmv021Ng E, Neff M.Recognising the return of nutritional deficiencies: a modern pellagra puzzle. BMJ Case Rep. 2018;11(1):e227454. doi:10.1136/bcr-2018-227454Badawy AA-B.Pellagra and alcoholism: a biochemical perspective.Alcohol Alcohol. 2014;49(3):238-250. doi:10.1093/alcalc/agu010Oldham MA, Ivkovic A.Pellagrous encephalopathy presenting as alcohol withdrawal delirium: a case series and literature review.Addict Sci Clin Pract. 2012;7(1):12. doi:10.1186/1940-0640-7-12Viljoen M, Bipath P, Roos JL.Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century.S Afr J Sci. 2018;114(9/10). doi:10.17159/sajs.2018/4597Additional ReadingWorld Health Organization.Pellagra and its prevention and control in major emergencies. Published 2000.
13 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Prabhu D, Dawe RS, Mponda K.Pellagra a review exploring causes and mechanisms, including isoniazid‐induced pellagra.Photodermatol Photoimmunol Photomed. 2021;37(2):99-104. doi:10.1111/phpp.12659Mills K, Akintayo O, Egbosiuba L, et al.Chronic diarrhea in a drinker: a breakthrough case of pellagra in the US South.J Investig Med High Impact Case Rep. 2020;8:232470962094130. doi:10.1177/2324709620941305Narasimha VL, Ganesh S, Reddy S, et al.Pellagra and alcohol dependence syndrome: findings from a tertiary care addiction treatment centre in India.Alcohol Alcohol. 2019;54(2):148-151. doi:10.1093/alcalc/agz004Pinheiro H, Matos Bela M, Leal AF, Nogueira L, Mesquita M.Hidden hunger: a pellagra case report.Cureus. 2021 Apr 25;13(4):e14682. doi:10.7759/cureus.14682Madhyastha SP, Shetty GV, Shetty VM, Reddy CT.The classic pellagra dermatitis.BMJ Case Rep. 2020;13(10):e239741. doi:10.1136/bcr-2020-239741Bilgili SG, Karadag AS, Calka O, Altun F.Isoniazid-induced pellagra.Cutan Ocul Toxicol. 2011;30(4):317-319. doi:10.3109/15569527.2011.574303MedlinePlus.Hartnup disease. Updated August 18, 2020.Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O.Pellagra: a clinical, histopathological, and epidemiological study of 7 cases.Actas Dermosifiliogr. 2012;103(1):51-58. doi:10.1016/j.adengl.2011.05.003Gupta Y, Shah I.Ethionamide-induced pellagra.J Trop Pediatr. 2015;61(4):301-303. doi:10.1093/tropej/fmv021Ng E, Neff M.Recognising the return of nutritional deficiencies: a modern pellagra puzzle. BMJ Case Rep. 2018;11(1):e227454. doi:10.1136/bcr-2018-227454Badawy AA-B.Pellagra and alcoholism: a biochemical perspective.Alcohol Alcohol. 2014;49(3):238-250. doi:10.1093/alcalc/agu010Oldham MA, Ivkovic A.Pellagrous encephalopathy presenting as alcohol withdrawal delirium: a case series and literature review.Addict Sci Clin Pract. 2012;7(1):12. doi:10.1186/1940-0640-7-12Viljoen M, Bipath P, Roos JL.Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century.S Afr J Sci. 2018;114(9/10). doi:10.17159/sajs.2018/4597Additional ReadingWorld Health Organization.Pellagra and its prevention and control in major emergencies. Published 2000.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Prabhu D, Dawe RS, Mponda K.Pellagra a review exploring causes and mechanisms, including isoniazid‐induced pellagra.Photodermatol Photoimmunol Photomed. 2021;37(2):99-104. doi:10.1111/phpp.12659Mills K, Akintayo O, Egbosiuba L, et al.Chronic diarrhea in a drinker: a breakthrough case of pellagra in the US South.J Investig Med High Impact Case Rep. 2020;8:232470962094130. doi:10.1177/2324709620941305Narasimha VL, Ganesh S, Reddy S, et al.Pellagra and alcohol dependence syndrome: findings from a tertiary care addiction treatment centre in India.Alcohol Alcohol. 2019;54(2):148-151. doi:10.1093/alcalc/agz004Pinheiro H, Matos Bela M, Leal AF, Nogueira L, Mesquita M.Hidden hunger: a pellagra case report.Cureus. 2021 Apr 25;13(4):e14682. doi:10.7759/cureus.14682Madhyastha SP, Shetty GV, Shetty VM, Reddy CT.The classic pellagra dermatitis.BMJ Case Rep. 2020;13(10):e239741. doi:10.1136/bcr-2020-239741Bilgili SG, Karadag AS, Calka O, Altun F.Isoniazid-induced pellagra.Cutan Ocul Toxicol. 2011;30(4):317-319. doi:10.3109/15569527.2011.574303MedlinePlus.Hartnup disease. Updated August 18, 2020.Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O.Pellagra: a clinical, histopathological, and epidemiological study of 7 cases.Actas Dermosifiliogr. 2012;103(1):51-58. doi:10.1016/j.adengl.2011.05.003Gupta Y, Shah I.Ethionamide-induced pellagra.J Trop Pediatr. 2015;61(4):301-303. doi:10.1093/tropej/fmv021Ng E, Neff M.Recognising the return of nutritional deficiencies: a modern pellagra puzzle. BMJ Case Rep. 2018;11(1):e227454. doi:10.1136/bcr-2018-227454Badawy AA-B.Pellagra and alcoholism: a biochemical perspective.Alcohol Alcohol. 2014;49(3):238-250. doi:10.1093/alcalc/agu010Oldham MA, Ivkovic A.Pellagrous encephalopathy presenting as alcohol withdrawal delirium: a case series and literature review.Addict Sci Clin Pract. 2012;7(1):12. doi:10.1186/1940-0640-7-12Viljoen M, Bipath P, Roos JL.Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century.S Afr J Sci. 2018;114(9/10). doi:10.17159/sajs.2018/4597
Prabhu D, Dawe RS, Mponda K.Pellagra a review exploring causes and mechanisms, including isoniazid‐induced pellagra.Photodermatol Photoimmunol Photomed. 2021;37(2):99-104. doi:10.1111/phpp.12659
Mills K, Akintayo O, Egbosiuba L, et al.Chronic diarrhea in a drinker: a breakthrough case of pellagra in the US South.J Investig Med High Impact Case Rep. 2020;8:232470962094130. doi:10.1177/2324709620941305
Narasimha VL, Ganesh S, Reddy S, et al.Pellagra and alcohol dependence syndrome: findings from a tertiary care addiction treatment centre in India.Alcohol Alcohol. 2019;54(2):148-151. doi:10.1093/alcalc/agz004
Pinheiro H, Matos Bela M, Leal AF, Nogueira L, Mesquita M.Hidden hunger: a pellagra case report.Cureus. 2021 Apr 25;13(4):e14682. doi:10.7759/cureus.14682
Madhyastha SP, Shetty GV, Shetty VM, Reddy CT.The classic pellagra dermatitis.BMJ Case Rep. 2020;13(10):e239741. doi:10.1136/bcr-2020-239741
Bilgili SG, Karadag AS, Calka O, Altun F.Isoniazid-induced pellagra.Cutan Ocul Toxicol. 2011;30(4):317-319. doi:10.3109/15569527.2011.574303
MedlinePlus.Hartnup disease. Updated August 18, 2020.
Piqué-Duran E, Pérez-Cejudo JA, Cameselle D, Palacios-Llopis S, García-Vázquez O.Pellagra: a clinical, histopathological, and epidemiological study of 7 cases.Actas Dermosifiliogr. 2012;103(1):51-58. doi:10.1016/j.adengl.2011.05.003
Gupta Y, Shah I.Ethionamide-induced pellagra.J Trop Pediatr. 2015;61(4):301-303. doi:10.1093/tropej/fmv021
Ng E, Neff M.Recognising the return of nutritional deficiencies: a modern pellagra puzzle. BMJ Case Rep. 2018;11(1):e227454. doi:10.1136/bcr-2018-227454
Badawy AA-B.Pellagra and alcoholism: a biochemical perspective.Alcohol Alcohol. 2014;49(3):238-250. doi:10.1093/alcalc/agu010
Oldham MA, Ivkovic A.Pellagrous encephalopathy presenting as alcohol withdrawal delirium: a case series and literature review.Addict Sci Clin Pract. 2012;7(1):12. doi:10.1186/1940-0640-7-12
Viljoen M, Bipath P, Roos JL.Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century.S Afr J Sci. 2018;114(9/10). doi:10.17159/sajs.2018/4597
World Health Organization.Pellagra and its prevention and control in major emergencies. Published 2000.
Meet Our Medical Expert Board
Share Feedback
Was this page helpful?Thanks for your feedback!What is your feedback?OtherHelpfulReport an ErrorSubmit
Was this page helpful?
Thanks for your feedback!
What is your feedback?OtherHelpfulReport an ErrorSubmit
What is your feedback?
