An unexpected case of pellagra

Clinical record An anxious 50-year-old woman presented with recurrence of a painful, well demarcated violaceous eruption with erythematous margins and large areas of blistering on her ankles and dorsa of her feet (Box 1, A). She had an erythematous desquamating rash on her hands, forearms and periorbital skin, with surrounding hyperpigmentation (Box 1, B). There were no signs of chronic liver disease, arterial insuffi ciency or sensory defi cit. Oral antibiotics and high-dose oral prednisolone had been ineff ective. She had no history of trauma or previous skin conditions. Sun exposure was an aggravating factor. She had recently started taking a herbal diuretic tablet and occasionally used ibuprofen and paracetamol for headaches. Her sister had an undiff erentiated connective tissue disease and a positive antinuclear antibody level. The patient was a smoker and reported drinking half a bottle of gin, amounting to at least 10 standard alcoholic drinks, per day.