Alcoholism a chronic condition affects multiple organ systems including skin ^1. Cutaneous markers of alcohol abuse are invaluable. Despite this, association of skin diseases and alcohol misuse maybe overlooked or physicians fail to explore.

Pellagra first described by Don Gasper Casal in 1735 is a multifactorial disease caused by Niacin/Tryptophan deficiency ². It exhibits photodermatitis, gastrointestinal and neuropsychiatric manifestations or the 4 D’s. Chronic alcoholics are at risk ³. Considering pellagra as differential diagnosis in chronic alcoholics with these symptoms is crucial. This disease is easily treatable but if missed proves fatal. Hence, its recognition is important in other clinical settings for comprehensive treatment.

Mr. R a 34-year-old married male from low socio-economic status previously employed as security guard in a medical college was referred from medicine where he presented seeking treatment for pain abdomen, and diarrhoea. After brief evaluation he was referred to psychiatry owing to history of alcohol use which seemed to be the root cause for all symptoms. Patient presented to psychiatry opd with 18 years of alcohol use suggestive of dependence pattern for past 14years, non-pervasive low mood for 6 months, pain abdomen, generalised weakness, nausea vomiting, significant weight loss, appetite disturbances for 4 months and diarrhoea for 20 days. His alcohol use precipitated in social setting, insidious onset, progressive course. Patient consumed 18-24units of spirits on average/day. Socio-occupational dysfunction and complaints at workplace due to alcohol use reported

No significant past/personal history. Discord with father + due to alcohol use. Patient was pre-morbidly well-adjusted.

GPE revealed tremors, tachycardia, beefy red tongue, oral ulcers and multiple distinct annular plaques with erythematous borders having hyperpigmented surrounding area with central clearing present over bilateral extensor aspects of forearms resembling a glove or Gauntlet. Patient didn’t self-report this rather on enquiry mentioned blistering and peeling of skin associated with burning and tenderness over hands for 4 months and concerns about how it looked. There was no involvement of any other region like face, neck, feet etc. Systemic examination normal.

On MSE patient appeared apathetic, spontaneity of speech lost, reduced psychomotor activity, cravings +, motivation poor, depressive cognition +. Deficits in recent memory +.

Pellagra is a chronic disease affecting integumentary, CNS and GIT due to deficiency of niacin/Tryptophan ⁴. Its multifactorial, however the commonest cause is alcoholism ⁵. Alcoholic liver disease which is present in half of alcohol dependent population also contributes to cutaneous findings ⁶. Poor diet, malabsorption of Pyridoxine and thiamine deficiency further contribute to it ⁷. Although outbreaks of Pellagra are common during crisis in developing countries but diagnosis is scarce and may be mistaken for vast array of diseases as the presentation often varies. The contemporary rarity of pellagra has limited scope of clinical exposure to the disease, causing failure to recognize, diagnose, and treat in its early stages ⁸. Several reports have commented on fatal consequences of delaying diagnosis ⁹. If diagnosed accurately and timely, skin lesions and other manifestations resolve quickly ¹⁰. A study published in 1981 states that in chronic alcoholics with certain neuropsychiatric and gastrointestinal symptoms Pellagra should be suspected even in absence of skin manifestations ⁹. The typical lesions occur over nape of neck known as Casals’s necklace and erythema occurs over sun-exposed areas ¹¹. However, in this case the highlight is the atypical presentation involving only dorsum of forearms and giving a burnt appearance excluding involvement of any other region. The oral mucosa is involved in 1/3^rd of cases presenting as ulcers, soreness and inflammation. GI symptoms include diarrhoea, reduced appetite, gastritis. Neuropsychiatric manifestations may present as headache, irritability, apathy, which if left untreated may progress to stupor, coma and eventually death ¹¹. It has an insidious onset and course and 1^st symptoms to usually present are rash and diarrhoea before neuropsychiatric manifestations. Hence, these maybe presented first to general physicians, dermatologists or gastroenterologists where it may be overlooked or missed ⁹. Patients if left untreated dementia sets in and can lead to death within 4-5years. Hence, consultation liaison psychiatry plays an important role here for sensitization and early treatment and prevention of neuropsychiatric sequelae.

Chronic alcoholics need evaluation for Pellagra amongst other nutritional deficiencies which due to diverse presentation can be missed. Early diagnosis and treatment can avoid impending neuropsychiatric complications. Due to participation of numerous disciplines consultation liaison psychiatry is vital here.