eMedicine Specialties > Dermatology > Internal Medicine

Pellagra: Differential Diagnoses & Workup

Author: Vladimir Hegyi, MD, PhD, Associate Professor, Department of Pediatric Dermatovenereology, Pediatric Hospital, Comenius University, Bratislava
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Apr 18, 2008

Differential Diagnoses

Atopic Dermatitis
Pemphigus, Drug-Induced
Drug Eruptions
Polymorphous Light Eruption
Hartnup Disease
Porphyria Cutanea Tarda
Lupus Erythematosus, Drug-Induced
Seborrheic Dermatitis
Lupus Erythematosus, Subacute Cutaneous
Pemphigus Vulgaris

Other Problems to Be Considered

Photodermatitis
Actinic reticuloid
Concomitant zinc deficiency
Pellagrous vulvitis
Pellagrous vaginitis
Pellagrous scrotal dermatitis
Contact dermatitis
Pyridoxine deficiency
Riboflavin deficiency
Vitamin B-12 deficiency

Drug eruptions - Distinguished by the drug history, clinical picture, localization, configuration, development of skin symptoms, and evidence of exposure to drug allergens

Dermatitis solaris - Distinguished by the history, clinical picture, monomorphism, localization, exposed sites, development of skin symptoms, lack of marked pigmentation, and fast healing

Eczema solare - Distinguished by the history, clinical picture, polymorphism, development of skin symptoms, lack of marked pigmentation, and itching

Eczema - Distinguished by the clinical picture, localization, development of skin symptoms, lack of marked pigmentation, and histology

Pemphigus vulgaris - Distinguished by the clinical picture, bullae on unchanged skin, localization, cytodiagnostics, and histologic features

Lupus erythematosus acutus et subacutus disseminatus - Distinguished by the general state, variable skin manifestation, infiltrates, red wine–colored transient erythemas on the palms and digits, lupus erythematosus phenomenon, proteinuria, and cylindruria

Chronic polymorphic light dermatoses - Distinguished by erythema on light-exposed sites, recurring papules, pruriginous nodules, lichenification, lack of marked pigmentation, and scaling

Hartnup syndrome - Recessive hereditary disorder distinguished by the malabsorption of tryptophan, pellagrous skin lesions, hypersensitivity to sun exposure, poikiloderma, onset in childhood, absence of mucous membrane disorder and diarrhea, various nervous and psychiatric aberrations, intermittent cerebellar ataxia, aminoaciduria, and marked indicanuria

Kwashiorkor - Distinguished by occurrence in children, dietary history, protein deficiency, generalized eruption, dermatitis with systemic signs of apathy and edema, thin and light hair, and high mortality rate

Porphyria cutanea tarda - Distinguished by bullae on exposed sites, bullae development after mechanical injury, porphyrins in the urine, and characteristic liver function test findings and medical findings in the liver

Porphyria variegata - Distinguished by erythema and bullae, skin and abdominal symptoms in attacks, and porphyrins in the urine and stool

Workup

Laboratory Studies

  • The therapeutic response to niacin in a patient with the typical symptoms and signs of pellagra establishes the diagnosis.
  • Blood counts (anemia), findings of hypoproteinemia, higher levels of serum calcium and lower levels of serum kalium and phosphorus, liver function test results, and serum porphyrin levels can help in diagnosing pellagra.
  • Low serum niacin, tryptophan, NAD, and NADP levels can reflect niacin deficiency and confirm the diagnosis of pellagra.
  • Low urinary levels of N- methylnicotinamide and pyridone suggest niacin deficiency and support the diagnosis of pellagra. The combined excretion of N- methylnicotinamide and pyridone of less than 1.5 mg in 24 hours indicates severe niacin deficiency.

Other Tests

  • Order other medical examinations as needed (eg, neurologic, psychiatric examinations).

Histologic Findings

Nonspecific dermatitic changes are usually evident. Early changes include a perivascular lymphohistologic infiltrate in the upper dermis, with mild edema in the papillary dermis; dilatation of capillaries; and, later, dermal fibrosis. Epidermal changes include early subcorneal blisters; pallor of the upper epidermis; and, later, hyperkeratosis, parakeratosis, and epidermal atrophy. In recurrences in the same site, blisters (pemphigus pellagrosus) contain lymphocytes, neutrophils, and histiocytes.

More on Pellagra

Overview: Pellagra
Differential Diagnoses & Workup: Pellagra
Treatment & Medication: Pellagra
Follow-up: Pellagra
References
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References

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Further Reading

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Keywords

avitaminosis, niacin deficiency, vitamin deficiency, vitamin B-3 deficiency

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Contributor Information and Disclosures

Author

Vladimir Hegyi, MD, PhD, Associate Professor, Department of Pediatric Dermatovenereology, Pediatric Hospital, Comenius University, Bratislava
Vladimir Hegyi, MD, PhD is a member of the following medical societies: European Academy of Dermatology and Venereology
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

James Fulton Jr, MD, PhD, Medical Director, Fulton Skin Institute
James Fulton Jr, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Cosmetic Surgery, American Academy of Dermatology, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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