Pellagra (Niacin / B3 Deficiency) C&P Exam Prep

Dermatological Assessment - Symmetrical Dermatitis

What it measures: Presence, distribution, and severity of the classic pellagrous dermatitis, typically appearing symmetrically on sun-exposed areas such as the neck (Casal necklace), hands, forearms, and face. May present as hyperpigmentation, scaling, cracking, weeping, or ulceration.

What to expect: The examiner will visually inspect skin on sun-exposed areas. They may ask about sensitivity to sunlight, burning, itching, and whether skin lesions weep, bleed, or become infected. They will note whether dermatitis is active or represents a residual/post-treatment finding.

Pain considerations: Describe any burning, painful cracking, or raw/weeping skin areas. Note if skin pain disturbs sleep or prevents wearing certain clothing.

Neurological Reflex Examination

What it measures: Peripheral neuropathy associated with chronic niacin deficiency, including assessment of deep tendon reflexes (knee and ankle jerks), sensory function, proprioception, and signs of foot drop or muscle atrophy of the thigh or leg.

What to expect: The examiner will use a reflex hammer to test knee and ankle jerks. They may test sensation using pinprick, light touch, or vibration. They will observe your gait and assess for muscle wasting. They may also evaluate for foot drop by asking you to walk on your heels.

Pain considerations: Neuropathic pain can be severe. Describe burning, electric shock sensations, or hypersensitivity to touch (allodynia) in affected limbs. Note the frequency and intensity on your worst days.

Mental Status Examination

What it measures: Cognitive and psychiatric manifestations of pellagra including confusion, memory impairment, depression, anxiety, irritability, psychosis, dementia, or Wernicke-Korsakoff syndrome attributable to chronic niacin deficiency.

What to expect: The examiner may ask orientation questions, assess short-term memory, and inquire about mood, behavior, and cognitive function. They will ask your family member or companion (if present) about observed changes in your behavior or cognition. This may be brief or more detailed depending on severity of symptoms.

Pain considerations: Mental symptoms in pellagra can cause significant emotional suffering. Describe depressive episodes, anxiety, emotional instability, and how these symptoms affect your worst days.

Gastrointestinal and Nutritional Assessment

What it measures: GI manifestations of pellagra including diarrhea, stomatitis (mouth inflammation), achlorhydria (absence of stomach acid), nausea, vomiting, weight loss, decreased appetite, and inability to retain food.

What to expect: The examiner will ask about bowel habits, frequency and character of diarrhea, oral sores, difficulty swallowing, and weight changes. They may examine the mouth and tongue for glossitis or stomatitis. They will assess for signs of malnutrition.

Pain considerations: Describe the pain and urgency of diarrhea, abdominal cramping, and how GI symptoms interrupt sleep, work, and social activities on your worst days.

Cardiovascular Assessment

What it measures: Cardiac complications of severe pellagra including cardiomegaly (enlarged heart) and congestive heart failure, which represent the most severe end of the disease spectrum.

What to expect: The examiner may auscultate the heart and lungs, check for edema (fluid retention in legs), and review any cardiac imaging or echocardiogram results in your records. They will assess for signs of anasarca (generalized edema).

Pain considerations: Describe chest discomfort, breathlessness with minimal exertion, and how cardiac symptoms limit your daily activities on your worst days.

10%

Non-specific symptoms only - such as decreased appetite, weight loss, fatigue, weakness, dizziness, or other mild systemic manifestations without confirmed diagnosis of active pellagra or residual findings following treatment that are minimal in nature.

From 38 CFR: Non-specific symptoms such as weakness, fatigue, anorexia, dizziness, and heaviness in the extremities at this level reflect the mildest compensable presentation under DC 6301.

30%

Confirmed diagnosis of pellagra with impaired bodily vigor. Symptoms include symmetrical dermatitis, mild mental symptoms (irritability, mild depression, forgetfulness), peripheral neuropathy with absent knee or ankle jerks and loss of sensation, stomatitis, achlorhydria, or diarrhea. Functioning is reduced but the veteran retains capacity for some daily activities.

From 38 CFR: Impaired bodily vigor combined with confirmed pellagra diagnosis and at least one of dermatitis, mental symptoms, peripheral neuropathy, or GI manifestations supports this rating tier under DC 6301.

60%

Marked mental changes, moist dermatitis, and inability to retain food. This triad represents severe pellagra with significant neuropsychiatric involvement, active weeping or moist skin lesions, and GI compromise severe enough to prevent adequate nutrition. Peripheral neuropathy with foot drop or atrophy of the thigh or leg may also be present.

From 38 CFR: The 60% criterion under DC 6301 requires the convergence of marked mental changes, moist dermatitis, and inability to retain food - representing severe systemic disease with multi-system involvement.

100%

Congestive heart failure, anasarca, or Wernicke-Korsakoff syndrome. This represents the most severe and life-threatening presentation of pellagra with critical cardiovascular, systemic fluid retention, or severe irreversible neurological compromise. The veteran requires significant assistance with activities of daily living.

From 38 CFR: Under DC 6301, the 100% rating is reserved for the most critical presentations: congestive heart failure, anasarca (total body edema), or Wernicke-Korsakoff syndrome - all of which represent life-threatening or severely disabling consequences of chronic niacin deficiency.

Dermatitis and Skin Manifestations

How to describe it: Describe the exact location of skin lesions (neck, hands, forearms, face), their appearance (red, scaling, cracking, weeping, hyperpigmented), and how they change with sun exposure. Quantify how often skin flares occur, how long they last, and what triggers them. Describe any infection, pain, or odor from weeping lesions. Explain how skin symptoms affect your ability to wear clothing, work outdoors, or engage in social activities.

Example: On my worst days, the skin on my neck and both forearms is raw, weeping, and extremely painful. I cannot wear a collar or long sleeves without the fabric sticking to the open areas. Even brief sun exposure causes the skin to blister and weep within an hour. The pain is a constant 7 out of 10 and the burning keeps me awake at night. I have avoided going outdoors entirely during spring and summer because of how severely my skin reacts.

Examiner listens for: Symmetry of skin involvement, sun-exposure relationship, presence of moist vs. dry dermatitis, infection history, functional limitations caused by skin symptoms, and correlation with pellagra diagnosis.

Avoid: Do not say 'my skin is just a little irritated' if you experience significant cracking, weeping, or infection. Do not minimize sun sensitivity. Do not fail to mention all affected body areas.

Mental and Cognitive Symptoms

How to describe it: Be specific about cognitive changes: describe memory failures with concrete examples, episodes of confusion or disorientation, mood instability, depression, or psychotic symptoms. Describe when these began, whether they are constant or episodic, and how they have changed over time. Explain the impact on your ability to manage finances, follow conversations, remember appointments, or maintain relationships.

Example: On my worst days, I cannot remember whether I have eaten or taken my medications. My family tells me I become agitated and say things that do not make sense. I have gotten lost driving in my own neighborhood twice this month. The confusion comes on suddenly and can last for hours. My wife handles all financial decisions now because I cannot reliably track numbers or follow multi-step processes.

Examiner listens for: Nature and severity of cognitive changes, onset and progression, impact on instrumental activities of daily living, whether symptoms meet criteria for marked mental changes versus mild irritability, and any formal neuropsychological testing.

Avoid: Do not say 'I'm just a little forgetful' if you have significant memory gaps or disorientation. Do not omit behavioral changes that family members have observed. Do not minimize depression or emotional instability as unrelated to your condition.

Gastrointestinal Symptoms

How to describe it: Describe the frequency and urgency of diarrhea with specific numbers (e.g., 8-10 loose stools per day on bad days). Describe nausea, vomiting, inability to eat, mouth sores that prevent chewing, and any associated weight loss with actual numbers. Explain how GI symptoms affect your ability to leave home, maintain employment, or eat a normal diet.

Example: On my worst days, I have 8 to 10 episodes of watery diarrhea with no warning. I am afraid to leave the house because I cannot reach a restroom in time. The sores inside my mouth and on my tongue make it impossible to eat anything but soft foods, and even water causes burning. I have lost 22 pounds over the past six months because I am afraid to eat. The nausea is constant and I vomit at least once daily during bad weeks.

Examiner listens for: Documented diarrhea frequency, stomatitis severity, achlorhydria findings, weight loss with quantification, inability to retain food as a distinct clinical finding, and correlation with nutritional deficiency.

Avoid: Do not say 'I have some loose stools' if you experience multiple episodes daily. Do not omit mouth sores or difficulty swallowing. Do not fail to mention your actual weight loss in pounds.

Peripheral Neuropathy Symptoms

How to describe it: Describe the exact sensations in your feet and legs: numbness, tingling, burning, electric shock feelings, or loss of balance. Note whether you have tripped, fallen, or needed a cane or other assistive device. Describe difficulty with stairs, uneven ground, or fine motor tasks. Explain how neuropathy affects your ability to stand, walk distances, or perform physical work.

Example: On my worst days, both my feet feel like they are encased in thick rubber gloves - I cannot feel the ground when I walk. I have fallen three times in the past two months because my right foot drags and catches on uneven surfaces. I cannot walk more than half a block without stopping due to weakness in my legs. At night the burning in my feet is so severe I cannot tolerate any sheet touching them and I average only 3-4 hours of sleep.

Examiner listens for: Objective signs of peripheral neuropathy (absent reflexes, sensory loss), presence of foot drop or muscle atrophy, functional impact on ambulation and daily activities, and correlation with pellagra-related niacin deficiency.

Avoid: Do not say 'my feet feel a little numb sometimes' if you have significant functional impairment. Do not fail to mention falls or use of assistive devices. Do not omit nighttime pain that disrupts sleep.

Systemic Weakness and Impaired Bodily Vigor

How to describe it: Describe your overall loss of stamina, endurance, and physical capacity compared to before your illness. Quantify what you can no longer do: distances you can walk, weight you can lift, duration of activity before exhaustion. Explain how fatigue affects your work, household responsibilities, and social life.

Example: On my worst days, I am exhausted after walking to the bathroom. I used to work a full eight-hour shift in a warehouse; now I cannot stand for more than ten minutes without needing to sit down. By noon I am too fatigued to do anything productive. I have had to reduce my work hours by 75% and I still cannot complete a full day without going to bed immediately afterward.

Examiner listens for: Quantifiable loss of functional capacity, correlation between fatigue and nutritional deficiency, impact on employability, and how impaired bodily vigor intersects with other pellagra manifestations.

Avoid: Do not say 'I get tired more easily' if you have profound functional limitation. Do not compare yourself only to healthy peers - compare to your own pre-illness baseline. Do not omit the occupational impact.