Niacin (nicotinic acid, nicotinamide) derivatives include nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP), which are coenzymes in oxidation-reduction reactions. They are vital in cell metabolism.
Dietary sources of niacinniacinniacin.
(See also Overview of Vitamins.)
Etiology of Niacin Deficiency
Primary niacin deficiency results from extremely inadequate intake of both niacinniacinniacin deficiency.
Secondary niacin deficiency may be due to diarrhea, cirrhosis, or alcohol use disorder. Pellagra also may occur in carcinoid syndromeHartnup disease
Symptoms and Signs of Niacin Deficiency
Pellagra is characterized by skin, mucous membrane, central nervous system, and gastrointestinal symptoms. Advanced pellagra can cause a symmetric photosensitive rash, stomatitis, glossitis, diarrhea, and mental aberrations. Symptoms may appear alone or in combination.
Skin symptoms include several types of lesions, which are usually bilaterally symmetric. The distribution of lesions—at pressure points or sun-exposed skin—is more pathognomonic than the form of the lesions. Lesions can develop in a glovelike distribution on the hands (pellagrous glove) or in a boot-shaped distribution on the feet and legs (pellagrous boot). Sunlight causes Casal necklace and butterfly-shaped lesions on the face.
© Springer Science+Business Media
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Image courtesy of Karen McKoy, MD.
Image courtesy of Karen McKoy, MD.
Image courtesy of Karen McKoy, MD.
© Springer Science+Business Media
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Image courtesy of Karen McKoy, MD.
Image courtesy of Karen McKoy, MD.
Image courtesy of Karen McKoy, MD.
Mucous membrane symptoms affect primarily the mouth but may also affect the vagina and urethra. Glossitis and stomatitis characterize acute deficiency. As the deficiency progresses, the tongue and oral mucous membranes become reddened, followed by pain in the mouth, increased salivation, and edema of the tongue. Ulcerations may appear, especially under the tongue, on the mucosa of the lower lip, and opposite the molar teeth.
Gastrointestinal symptoms early in the deficiency include burning in the pharynx and esophagus and abdominal discomfort and distention. Constipation is common. Later, nausea, vomiting, and diarrhea may occur. Diarrhea is often bloody because of bowel hyperemia and ulceration.
Central nervous system symptoms include psychosis, encephalopathy (characterized by impaired consciousness), and cognitive decline (dementia). Psychosis is characterized by memory impairment, disorientation, confusion, and confabulation; the predominant symptom may be excitement, depression, mania, delirium, or paranoia.
Diagnosis of Niacin Deficiency
Clinical evaluation
Diagnosis of niacin deficiency is clinical and may be straightforward when skin and mouth lesions, diarrhea, delirium, and dementia occur simultaneously. More often, the presentation is not so specific. Differentiating the central nervous system changes from those in thiamin deficiency is difficult. A history of a diet lacking niacinniacin can usually confirm it.
If available, laboratory testing can help confirm the diagnosis, particularly when the diagnosis is otherwise unclear. Urinary excretion of N1-methylnicotinamide (NMN) is decreased; < 0.8 mg/day (< 5.8 mcmol/day) suggests a niacin deficiency.
Treatment of Niacin Deficiency
Nicotinamide and other nutrients
Nicotinamide is usually used to treat niacin deficiency, because nicotinamide, unlike nicotinic acid (the most common form of niacin), does not cause flushing, itching, burning, or tingling sensations. Nicotinamide is given in doses of 250 to 500 mg orally daily.
Key Points
Niacin deficiency can cause pellagra, mainly in countries with high rates of food insecurity.
Pellagra causes a photosensitivity rash, mucositis, gastrointestinal disturbances, and neuropsychiatric dysfunction.
Diagnose clinically if possible.
Use nicotinamide to treat the deficiency; a favorable response can confirm the diagnosis.
