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A 13 year old boy presented to a field hospital in West Darfur, Sudan, with a mildly pruritic rash for six months involving the face, upper chest, and distal extremities. The facial eruption was characterised by hyperpigmentation and areas of peeling resembling sunburn. Lesions of the forearms, hands, and feet were strikingly symmetrical, hyperpigmented, thickened, and scaly. There was a clear zone of demarcation between affected and normal skin. No gastrointestinal or neurological disturbances were present and physical examination was otherwise unremarkable. The patient’s diet consisted solely of locally prepared dura, or cooked millet, without milk or other sources of animal protein. Given the history and the particular characteristics of the dermatitis—photosensitivity,“stocking glove” forearm distribution, and well defined involvement of the upper chest (often referred to as “Casal’s necklace”)—a presumptive diagnosis of pellagra secondary to dietary niacin deficiency was established.1 Of note, the word “pellagra” derives from the Italian,“pelle agra”, meaning “sour (or rough) skin”. Oral replacement with 90 mg of nicotinic acid once daily was initiated. Significant improvement was noted when the patient returned for follow up at approximately one month.
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