<P> There are two main types of pellagra, primary and secondary . Primary pellagra is due to a diet that does not contain enough niacin and tryptophan . Secondary pellagra is due to a poor ability to use the niacin within the diet . This can occur as a result of alcoholism, long term diarrhea, carcinoid syndrome, Hartnup disease, and a number of medications such as isoniazid . Diagnosis is typically based on symptoms and may be assisted by urine testing . </P> <P> Treatment is with either niacin or nicotinamide supplementation . Improvements typically begin within a couple of days . General improvements in diet are also frequently recommended . Decreasing sun exposure via sunscreen and proper clothing is important while the skin heals . Without treatment death may occur . It occurs most commonly in the developing world, specifically sub-Saharan Africa . </P> <P> The classic symptoms of pellagra are diarrhea, dermatitis, dementia, and death ("the four Ds"). A more comprehensive list of symptoms includes: </P> <Ul> <Li> High sensitivity to sunlight </Li> <Li> Aggression </Li> <Li> Dermatitis, alopecia (hair loss), edema (swelling) </Li> <Li> Smooth, beefy red glossitis (tongue inflammation) </Li> <Li> Red skin lesions </Li> <Li> Insomnia </Li> <Li> Weakness </Li> <Li> Mental confusion </Li> <Li> Ataxia (lack of coordination), paralysis of extremities, peripheral neuritis (nerve damage) </Li> <Li> Diarrhea </Li> <Li> Dilated cardiomyopathy (enlarged, weakened heart) </Li> <Li> Eventually dementia </Li> </Ul>

The signs and symptoms of include dermatitis dementia diarrhea