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Latest revision as of 14:20, 26 July 2016

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

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Overview

Pellagra is a vitamin deficiency disease caused by dietary lack of niacin (vitamin B3) and protein, especially proteins containing the essential amino acid tryptophan.^[1] Because tryptophan can be converted into niacin, foods with tryptophan but without niacin, such as milk, prevent pellagra. However, if dietary tryptophan is diverted into protein production, niacin deficiency may still result.

Tryptophan is an essential amino acid found in meat, poultry, fish, and eggs. If your diet contains these foods, your need for niacin from other sources will be reduced.^[2]

The relationship between lysine and pellagra is unclear.^[3]

Historical Perspective

The traditional food preparation method of corn, nixtamalization, by native New World cultivators, who had domesticated corn, required treatment of the grain with lime, an alkali. It has now been shown that the lime treatment makes niacin nutritionally available and reduces the chance of developing pellagra. When corn cultivation was adopted worldwide, this preparation method was not accepted because the benefit was not understood. The original cultivators, often heavily dependent on corn, did not suffer from pellagra. Pellagra became common only when corn became a staple that was eaten without the traditional treatment.

Pellagra was first described in Spain in 1735 by Gaspar Casal, who published a first clinical description in his posthumous "Natural and Medical History of the Asturian Pricipality" (1762). This led to the disease being knownn as "Asturian leprosy", and it is recognised as the first modern pathological description of a syndrome(1). It was an endemic disease in northern Italy, where it was named "pelle agra" (pelle = skin; agra = rough) by Francesco Frapoli of Milan.^[4] Because pellagra outbreaks occurred in regions where maize was a dominant food crop, the belief for centuries was that the maize either carried a toxic substance or was a carrier of disease. It was not until later that the lack of pellagra outbreaks in Mesoamerica, where maize is a major food crop (and is processed), that the idea was considered that the causes of pellagra may be due to factors other than toxins.

In the early 1900s, pellagra reached epidemic proportions in the American South. There were 1,306 reported pellagra deaths in South Carolina during the first ten months of 1915; 100,000 Southerners were affected in 1916. At this time, the scientific community held that pellagra was probably caused by a germ or some unknown toxin in corn.^[5] The Spartanburg Pellagra Hospital in Spartanburg, South Carolina, was the nation's first facility dedicated to discovering the cause of pellagra. It was established in 1914 with a special congressional appropriation to the U.S. Public Health Service (PHS) and set up primarily for research. In 1915 Joseph Goldberger, assigned to study pellagra by the Surgeon General of the United States, showed that pellagra was linked to diet by inducing the disease in prisoners, using the Spartanburg Pellagra Hospital as his clinic. By 1926, Goldberger established that a balanced diet or a small amount of baker's yeast prevented pellagra. Skepticism still persisted in the medical community until 1937 when Conrad Elvehjem showed that the vitamin niacin cured pellagra (manifested as black tongue) in dogs. Later studies by Tom Spies, Marion Blankenhorn and Clark Cooper established that niacin also cured pellagra in humans, for which Time Magazine dubbed them its 1938 Men of the Year in comprehensive science.

Classification

Pathophysiology

Causes

Drug Causes

Isoniazid

Differentiating Pellagra from Other Diseases

Epidemiology and Demographics

Pellagra can be common in people who obtain most of their food energy from maize, since untreated corn is a poor source of niacin (vitamin B3). Corn is also a poor source of tryptophan. This disease can be common among people who live in rural South America where corn is a staplea. The symptoms usually appear during spring, increase in the summer due to greater sun exposure, and return the following spring. It is also one of several diseases of malnutrition common in Africa, and was endemic in the poorer states of the U.S. south like Mississippi and Alabama as well as among the inmates of jails and orphanages, where it was studied by Joseph Goldberger who conducted experiments in the penal colony in Rankin. Alkali treatment of the corn corrects the niacin deficiency, and was a common practice in native American cultures that grew corn. The amino acid deficiency must be balanced by consumption of other sources of protein. It was also common amongst prisoners of Soviet labor camps, the infamous Gulag. Also found in cases of chronic alcoholism.

Risk Factors

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Symptoms

The symptoms of pellagra include:

The main results of pellagra can easily be remembered as "the four D's": diarrhea, dermatitis, dementia, and death.^[6]

Physical Examination

Skin

Laboratory Findings

Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

↑ Pitche P (2005). "Pellagra". Sante. 15 (3): 205–8. PMID 16207585.
↑ Haas EM. "Vitamin B3—Niacin". Excepted from: Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine. Retrieved 2007-06-18.
↑ Bapurao S, Krishnaswamy K (1978). "Vitamin B6 nutritional status of pellagrins and their leucine tolerance". Am J Clin Nutr. 31 (5): 819–24. PMID 206127.
↑ "Definition of Pellagra". MedicineNet.com. Retrieved 2007-06-18.
↑ Bollet A (1992). "Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century". Yale J Biol Med. 65 (3): 211–21. PMID 1285449.
↑ Hegyi J, Schwartz R, Hegyi V (2004). "Pellagra: dermatitis, dementia, and diarrhea". Int J Dermatol. 43 (1): 1–5. PMID 14693013.
↑ ^7.00 ^7.01 ^7.02 ^7.03 ^7.04 ^7.05 ^7.06 ^7.07 ^7.08 ^7.09 ^7.10 ^7.11 ^7.12 ^7.13 ^7.14 ^7.15 ^7.16 ^7.17 ^7.18 ^7.19 ^7.20 ^7.21 ^7.22 ^7.23 ^7.24 ^7.25 ^7.26 ^7.27 ^7.28 ^7.29 ^7.30 ^7.31 ^7.32 ^7.33 ^7.34 ^7.35 ^7.36 ^7.37 ^7.38 ^7.39 ^7.40 ^7.41 ^7.42 ^7.43 ^7.44 ^7.45 ^7.46 ^7.47 ^7.48 ^7.49 ^7.50 ^7.51 ^7.52 ^7.53 ^7.54 ^7.55 ^7.56 ^7.57 ^7.58 ^7.59 ^7.60 ^7.61 "Dermatology Atlas".

Template:WH Template:WS

[Pitche_2005-1] Pitche P (2005). "Pellagra". Sante. 15 (3): 205–8. PMID 16207585.

[2] Haas EM. "Vitamin B3—Niacin". Excepted from: Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine. Retrieved 2007-06-18.

[Bapurao_1978-3] Bapurao S, Krishnaswamy K (1978). "Vitamin B6 nutritional status of pellagrins and their leucine tolerance". Am J Clin Nutr. 31 (5): 819–24. PMID 206127.

[4] "Definition of Pellagra". MedicineNet.com. Retrieved 2007-06-18.

[Bollet_1992-5] Bollet A (1992). "Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century". Yale J Biol Med. 65 (3): 211–21. PMID 1285449.

[Hegyi_2004-6] Hegyi J, Schwartz R, Hegyi V (2004). "Pellagra: dermatitis, dementia, and diarrhea". Int J Dermatol. 43 (1): 1–5. PMID 14693013.

[Dermatology_Atlas-7] 7.00 ^7.01 ^7.02 ^7.03 ^7.04 ^7.05 ^7.06 ^7.07 ^7.08 ^7.09 ^7.10 ^7.11 ^7.12 ^7.13 ^7.14 ^7.15 ^7.16 ^7.17 ^7.18 ^7.19 ^7.20 ^7.21 ^7.22 ^7.23 ^7.24 ^7.25 ^7.26 ^7.27 ^7.28 ^7.29 ^7.30 ^7.31 ^7.32 ^7.33 ^7.34 ^7.35 ^7.36 ^7.37 ^7.38 ^7.39 ^7.40 ^7.41 ^7.42 ^7.43 ^7.44 ^7.45 ^7.46 ^7.47 ^7.48 ^7.49 ^7.50 ^7.51 ^7.52 ^7.53 ^7.54 ^7.55 ^7.56 ^7.57 ^7.58 ^7.59 ^7.60 ^7.61 "Dermatology Atlas".

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[6]

[7]

@@ Line 1: / Line 1: @@
-{{CMG}}; {{AE}} {{KS}}
+__NOTOC__
+{{SI}}
+{{CMG}}; {{AE}}
+{{PleaseHelp}}
 ==Overview==
-{{DiseaseDisorder infobox |
-  Name           = Pellagra |
-  Image          = Pellagra NIH.jpg |
-  Caption        = Pellagra sufferer with [[skin lesion]]s|
-  ICD10          = {{ICD10|E|52||e|50}} |
-  ICD9           = {{ICD9|265.2}} |
-  ICDO           = |
-  OMIM           = |
-  DiseasesDB     = 9730 |
-  MedlinePlus    = 000342 |
-  eMedicineSubj  = ped |
-  eMedicineTopic = 1755 |
-  MeshName       = Pellagra |
-  MeshNumber     = C18.654.521.500.133.699.529 |
-}}
-{{Search infobox}}
 '''Pellagra''' is a [[vitamin]] [[deficiency disease]] caused by dietary lack of [[niacin]] (vitamin B3) and [[protein]], especially proteins containing the [[essential amino acid]] [[tryptophan]].<ref name=Pitche_2005>{{cite journal |author=Pitche P |title=Pellagra |journal=Sante |volume=15 |issue=3 |pages=205-8 |year=2005 |pmid = 16207585}}</ref> Because tryptophan can be [[Niacin#Biosynthesis|converted into niacin]], foods with tryptophan but without niacin, such as [[milk]], prevent pellagra. However, if dietary tryptophan is diverted into protein production, niacin deficiency may still result.
@@ Line 26: / Line 12: @@
 The relationship between [[lysine]] and pellagra is unclear.<ref name=Bapurao_1978>{{cite journal |author=Bapurao S, Krishnaswamy K |title=Vitamin B6 nutritional status of pellagrins and their leucine tolerance |journal=Am J Clin Nutr |volume=31 |issue=5 |pages=819-24 |year=1978 |pmid = 206127}}</ref>
+==Historical Perspective==
+[[Image:Joseph Goldberger 01.jpg|thumb|100px|left|Portrait of Dr. Joseph Goldberger]]
+The traditional food preparation method of corn, [[nixtamalization]], by native New World cultivators, who had domesticated corn, required treatment of the grain with [[calcium hydroxide|lime]], an [[alkali]]. It has now been shown that the lime treatment makes niacin nutritionally available and reduces the chance of developing pellagra. When corn cultivation was adopted worldwide, this preparation method was not accepted because the benefit was not understood. The original cultivators, often heavily dependent on corn, did not suffer from pellagra. Pellagra became common only when corn became a staple that was eaten without the traditional treatment.
+Pellagra was first described in Spain in 1735 by Gaspar Casal, who published a first clinical description in his posthumous "Natural and Medical History of the Asturian Pricipality" (1762). This led to the disease being knownn as "Asturian leprosy", and it is recognised as the first modern pathological description of a syndrome(1).  It was an endemic disease in northern Italy, where it was  named "pelle agra" (pelle = skin; agra = rough) by Francesco Frapoli of Milan.<ref>{{cite web | title = Definition of Pellagra| work = MedicineNet.com | url = http://www.medterms.com/script/main/art.asp?articlekey=4821 | accessdate = 2007-06-18}}</ref>  Because pellagra outbreaks occurred in regions where [[maize]] was a dominant food crop, the belief for centuries was that the maize either carried a toxic substance or was a carrier of disease. It was not until later that the lack of pellagra outbreaks in Mesoamerica, where maize is a major food crop (and is processed), that the idea was considered that the causes of pellagra may be due to factors other than toxins.
+In the early 1900s, pellagra reached epidemic proportions in the American South. There were 1,306 reported pellagra deaths in South Carolina during the first ten months of 1915; 100,000 Southerners were affected in 1916. At this time, the scientific community held that pellagra was probably caused by a [[germ]] or some unknown [[toxin]] in corn.<ref name=Bollet_1992>{{cite journal |author=Bollet A |title=Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century |journal=Yale J Biol Med |volume=65 |issue=3 |pages=211-21 |year= 1992|pmid = 1285449}}</ref> The Spartanburg Pellagra Hospital in Spartanburg, South Carolina, was the nation's first facility dedicated to discovering the cause of pellagra. It was established in 1914 with a special congressional appropriation to the U.S. Public Health Service (PHS) and set up primarily for research.  In 1915 [[Joseph Goldberger]], assigned to study pellagra by the [[Surgeon General of the United States]], showed that pellagra was linked to diet by inducing the disease in prisoners, using the Spartanburg Pellagra Hospital as his clinic. By 1926, Goldberger established that a balanced diet or a small amount of baker's yeast prevented pellagra. Skepticism still persisted in the medical community until  1937 when [[Conrad Elvehjem]] showed that the vitamin niacin cured pellagra (manifested as [[Black hairy tongue|black tongue]]) in dogs. Later studies by Tom Spies, Marion Blankenhorn and Clark Cooper established that niacin also cured pellagra in humans, for which ''Time'' Magazine dubbed them its 1938 Men of the Year in comprehensive science.
+==Classification==
+==Pathophysiology==
+==Causes==
+===Drug Causes===
+* [[Isoniazid]]
+==Differentiating {{PAGENAME}} from Other Diseases==
+==Epidemiology and Demographics==
+Pellagra can be common in people who obtain most of their [[food energy]] from [[maize]], since untreated corn is a poor source of [[niacin]] (vitamin B3). Corn is also a [[Essential amino acid#Use of essential amino acids|poor source of tryptophan]].  This disease can be common among people who live in rural South America where corn is a staplea. The symptoms usually appear during spring, increase in the summer due to greater sun exposure, and return the following spring. It is also one of several diseases of malnutrition common in Africa, and was [[endemic (epidemiology)|endemic]] in the poorer states of the U.S. south like Mississippi and Alabama as well as among the inmates of jails and orphanages, where it was studied by [[Joseph Goldberger]] who conducted experiments in the penal colony in Rankin. Alkali treatment of the corn corrects the niacin deficiency, and was a common practice in native American cultures that grew corn. The amino acid deficiency must be balanced by consumption of other sources of protein. It was also common amongst prisoners of Soviet labor camps, the infamous Gulag. Also found in cases of chronic alcoholism.
+==Risk Factors==
+==Screening==
+==Natural History, Complications, and Prognosis==
+===Natural History===
+===Complications===
+===Prognosis===
+==Diagnosis==
+===Diagnostic Criteria===
+===History and Symptoms===
 ==Symptoms==
 The symptoms of pellagra include:
@@ Line 41: / Line 62: @@
 The main results of pellagra can easily be remembered as "the four D's": diarrhea, dermatitis, dementia, and death.<ref name=Hegyi_2004>{{cite journal |author=Hegyi J, Schwartz R, Hegyi V |title=Pellagra: dermatitis, dementia, and diarrhea |journal=Int J Dermatol |volume=43 |issue=1 |pages=1-5 |year=2004 |pmid = 14693013}}</ref>
-==Diagnosis==
 ===Physical Examination===
+==Physical Examination==
 ====Skin====
 =====Neck=====
 <gallery>
-Image:Pellagra02.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra02.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra03.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra03.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra12.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra12.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra13.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra13.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra36.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra36.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
@@ Line 67: / Line 89: @@
-Image:Pellagra47.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra47.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra48.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra48.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra25.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra25.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra33.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra33.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 </gallery>
@@ Line 81: / Line 103: @@
 <gallery>
-Image:Pellagra19.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra19.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra32.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra32.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra39.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra39.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 </gallery>
-======Trunk=====
+=====Trunk=====
 <gallery>
-Image:Pellagra23.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra23.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra24.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra24.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra43.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra43.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra45.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra45.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Image:Pellagra46.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra46.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 </gallery>
-==Epidemiology==
+=====Extremity=====
-Pellagra can be common in people who obtain most of their [[food energy]] from [[maize]], since untreated corn is a poor source of [[niacin]] (vitamin B3). Corn is also a [[Essential amino acid#Use of essential amino acids|poor source of tryptophan]].  This disease can be common among people who live in rural South America where corn is a staple. The symptoms usually appear during spring, increase in the summer due to greater sun exposure, and return the following spring. It is also one of several diseases of malnutrition common in Africa, and was [[endemic (epidemiology)|endemic]] in the poorer states of the U.S. south like Mississippi and Alabama as well as among the inmates of jails and orphanages, where it was studied by [[Joseph Goldberger]] who conducted experiments in the penal colony in Rankin. Alkali treatment of the corn corrects the niacin deficiency, and was a common practice in native American cultures that grew corn. The amino acid deficiency must be balanced by consumption of other sources of protein. It was also common amongst prisoners of Soviet labor camps, the infamous Gulag. Also found in cases of chronic alcoholism.
+<gallery>
+Image:Pellagra04.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra05.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-==Prognosis==
+Image:Pellagra06.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Untreated, the disease can kill within four or five years.
-Pellagra can be treated by treatment with niacin (usually as niacinamide). The frequency and amount of niacinamide administered depends on the degree to which the condition has progressed.
-==History==
+Image:Pellagra07.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-[[Image:Joseph Goldberger 01.jpg|thumb|100px|left|Portrait of Dr. Joseph Goldberger]]
-The traditional food preparation method of corn, [[nixtamalization]], by native New World cultivators, who had domesticated corn, required treatment of the grain with [[calcium hydroxide|lime]], an [[alkali]]. It has now been shown that the lime treatment makes niacin nutritionally available and reduces the chance of developing pellagra. When corn cultivation was adopted worldwide, this preparation method was not accepted because the benefit was not understood. The original cultivators, often heavily dependent on corn, did not suffer from pellagra. Pellagra became common only when corn became a staple that was eaten without the traditional treatment.
+Image:Pellagra08.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra09.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra10.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra11.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra14.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra15.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra16.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra17.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra18.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra20.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra21.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra22.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra26.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra27.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra28.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra29.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra30.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra34.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra35.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra37.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra38.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra40.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra41.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra42.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra44.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra49.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra50.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra51.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra53.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra54.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra55.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra56.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra57.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra58.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra59.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra60.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra61.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra62.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra63.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra64.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Pellagra was first described in Spain in 1735 by Gaspar Casal, who published a first clinical description in his posthumous "Natural and Medical History of the Asturian Pricipality" (1762). This led to the disease being knownn as "Asturian leprosy", and it is recognised as the first modern pathological description of a syndrome(1).  It was an endemic disease in northern Italy, where it was  named "pelle agra" (pelle = skin; agra = rough) by Francesco Frapoli of Milan.<ref>{{cite web | title = Definition of Pellagra| work = MedicineNet.com | url = http://www.medterms.com/script/main/art.asp?articlekey=4821 | accessdate = 2007-06-18}}</ref>  Because pellagra outbreaks occurred in regions where [[maize]] was a dominant food crop, the belief for centuries was that the maize either carried a toxic substance or was a carrier of disease. It was not until later that the lack of pellagra outbreaks in Mesoamerica, where maize is a major food crop (and is processed), that the idea was considered that the causes of pellagra may be due to factors other than toxins.
-In the early 1900s, pellagra reached epidemic proportions in the American South. There were 1,306 reported pellagra deaths in South Carolina during the first ten months of 1915; 100,000 Southerners were affected in 1916. At this time, the scientific community held that pellagra was probably caused by a [[germ]] or some unknown [[toxin]] in corn.<ref name=Bollet_1992>{{cite journal |author=Bollet A |title=Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century |journal=Yale J Biol Med |volume=65 |issue=3 |pages=211-21 |year= 1992|pmid = 1285449}}</ref> The Spartanburg Pellagra Hospital in Spartanburg, South Carolina, was the nation's first facility dedicated to discovering the cause of pellagra. It was established in 1914 with a special congressional appropriation to the U.S. Public Health Service (PHS) and set up primarily for research.  In 1915 [[Joseph Goldberger]], assigned to study pellagra by the [[Surgeon General of the United States]], showed that pellagra was linked to diet by inducing the disease in prisoners, using the Spartanburg Pellagra Hospital as his clinic. By 1926, Goldberger established that a balanced diet or a small amount of baker's yeast prevented pellagra. Skepticism still persisted in the medical community until  1937 when [[Conrad Elvehjem]] showed that the vitamin niacin cured pellagra (manifested as [[Black hairy tongue|black tongue]]) in dogs. Later studies by Tom Spies, Marion Blankenhorn and Clark Cooper established that niacin also cured pellagra in humans, for which ''Time'' Magazine dubbed them its 1938 Men of the Year in comprehensive science.
+Image:Pellagra65.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-==References==
+</gallery>
-<!-- ---------------------------------------------------------------
-See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for a
-discussion of different citation methods and how to generate
-footnotes using the <ref> & </ref> tags and the {{Reflist}} template
--------------------------------------------------------------------- -->
-{{Reflist|2}}
+===Laboratory Findings===
-===Other reading===
+===Imaging Findings===
-(1) Stratigos JD, Katsambas A. Pellagra: a still existing disease. B J
-Dermatol 1977; 96: 99-106.
-<div class="references-small" style="-moz-column-count:2; column-count:2;">
-* {{cite journal | author = Hampl JS, Hampl WS. | title = Pellagra and the origin of a myth: evidence from European literature and folklore. | journal = J Roy Soc Med. | year = 1997 | volume = 90 | issue = | pages = 636&ndash;639 | url= http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1296679}}
-* {{cite journal | author = | title =  Reports and Resolutions of the General Assembly of the State of South Carolina, Regular Session Commencing January 11, 1916. | journal = Annual Report of the State Board of Health (1915-1916). | year = 1916 | location = Columbia, S.C. | volume = 4 | publisher = Gonzales and Bryan, state printers | url = }}
-* {{cite book |author=Beardsley E | title=The Spartanburg Pellagra Hospital. In: The South Carolina Encyclopedia |publisher=University of South Carolina Press |location=Columbia, S.C |year=2006 |pages= |isbn=1-57003-598-9}}
-</div>
-==External links==
+===Other Diagnostic Studies===
-* {{DermNet|systemic/pellagra}}
-* [http://www.cyberparent.com/alternativehealth/pellagra.htm cyberparent.com]
-* [http://www.wholegrain.umn.edu/grains/corn.cfm wholegrain.umn.edu]
+==Treatment==
+===Medical Therapy===
-{{Nutritional pathology}}
+===Surgery===
-[[Category:Malnutrition]]
+===Prevention===
-[[Category:Gastroenterology]]
-[[da:Pellagra]]
+==References==
-[[de:Pellagra]]
+{{reflist|2}}
-[[es:Pelagra]]
-[[fr:Pellagre]]
-[[fur:Mâl de spelaie]]
-[[it:Pellagra]]
-[[he:פלגרה]]
-[[hu:Pellagra]]
-[[nl:Niacinedeficiëntie]]
-[[ja:ペラグラ]]
-[[pl:Rumień lombardzki]]
-[[pt:Pelagra]]
-[[ro:Pelagră]]
-[[ru:Пеллагра]]
-[[simple:Pellagra]]
-[[sv:Pellagra]]
-[[vec:Pelagra]]
 {{WH}}
-{{WikiDoc Sources}}
+{{WS}}
+[[Category:Endocrinology]]

Pellagra: Difference between revisions

Latest revision as of 14:20, 26 July 2016

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Drug Causes

Differentiating Pellagra from Other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Symptoms

Physical Examination

Physical Examination

Skin

Neck

Face

Trunk

Extremity

Laboratory Findings

Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

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