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Casal Necklace Sign: Understanding its Significance

Casal Necklace Sign is a medical term used to describe a ring-like pigmentation around the neck commonly associated with a deficiency of niacin or Vitamin B3. This condition is also known as Casal's Collar. The term was first coined by Gaspar Casal, a Spanish physician, in 1762. In this article, we will take a closer look at the Casal Necklace Sign and its significance.


casal necklace sign

What is the Casal Necklace Sign?

The Casal Necklace Sign is a dermatatis characterized by a brownish or dark ring-like pigmentation around the neck. The pigmentation usually appears on the sides and back of the neck and is often symmetrical.

This pigmentation is caused by a buildup of a substance called melanin in the skin. Melanin is responsible for giving color to our hair, skin, and eyes. A low level of Vitamin B3 can lead to an excess of melanin in the skin, resulting in the Casal's Collar.



As mentioned earlier, the Casal's Collar sign  is caused by a low level of Vitamin B3. Niacin is an essential nutrient that our bodies require to function properly. It is involved in several important processes, including energy production, DNA repair, and nervous system function.

A low level in blood patient can lead to a medical condition called pellagra, which is characterized by several symptoms, including the Casal's Collar. In this chapter of this article, we will take a closer look at the causes of pellagra.

Inadequate Intake

The most common clinical cause is inadequate intake. Niacin is found in a variety of foods, including meat, fish, and poultry. However, patients who follow a vegetarian or vegan diet may be at risk if they do not consume enough niacinamid-rich foods.

Impaired Absorption

Impaired absorption of vitamin B3 can also lead to a low blood level. Health conditions that affect the digestive system, such patients with inflammatory bowel disease or celiac disease, can interfere with the absorption of vitamin B3.


Alcoholism is another cause. Alcohol interferes with the absorption and utilization of vitamin B3 in the body.


Certain medications can also interfere with the absorption and utilization of vitamin B3 in the body. Examples include isoniazid, a medication used to treat tuberculosis, and 6-mercaptopurine, a medication used to treat leukemia.

Genetic Disorders

Rare genetic disorders, such patients with Hartnup disease and tryptophanuria, can also lead to this clinical figure. These disorders affect the absorption and utilization of B3 in the body.

Pellagra Symptoms Associated with Casal Necklace Sign

Apart from the ring-like pigmentation around the neck, patient with pellagra may also experience other clinical symptoms. In this chapter of this article, we will take a closer look at the symptoms associated with this medical figure.


One of the most common clinical symptoms associated of pellagra is fatigue. Patient may experience fatigue and weakness. B3 is involved in the production of ATP, which is the main energy currency of the body. Without enough niacin, the body may not produce enough ATP, leading to fatigue and weakness.


Diarrhea is another common symptom in pellagra. Niacinamid plays an important role in the health of the digestive system. It is involved in the production of hydrochloric acid, which helps break down food in the stomach.


Dermatitis is a skin condition that causes red, itchy, and inflamed skin. Dermatitis is another symptom that may be be present in pellagra. This dermatatis may be associated with clinical Casal's Collar sign.


Depression is a mood disorder that is characterized by persistent feelings of sadness and hopelessness. It is another clinical symptom that may be present in the patient with pellagra. Niacin is involved in the production of serotonin, a neurotransmitter that plays a role in regulating mood. 

Pellagra can lead to a decrease in serotonin levels, which may contribute to the development of depression in patient.

Cognitive impairment

Cognitive impairment refers to a decline in cognitive function, including memory, attention, and reasoning. It is another symptom that may be associated with the Casal Necklace Sign. B3 plays an important role in brain function. Patient may express a clinical symptoms of cognitive impairment.


Headaches are a common symptom of pellagra. Niacin plays a role in the health of blood vessels. Patient with pellagra may express headaches.

Loss of appetite

Loss of appetite is another clinical symptom that may be prsent in patient with pellagra.



Now that we have discussed the causes and symptoms, let's take a look at the treatment options available for this medical condition.

Niacin Supplements

The most effective treatment for the Casal Necklace Sign is niacin supplementation. It is available in different forms, including nicotinic acid, niacinamide, and inositol hexanicotinate. These supplements are available over the counter and can be taken orally.

Supplements are available in different strengths, and the appropriate dose depends on the the B3 level. It is important to consult a healthcare provider before taking niacin supplements to determine the appropriate dose.

Dietary Changes

In addition to supplementation, making dietary changes can also help treat the Casal's Collar. Foods that are rich in niacin include:

  • Beef liver
  • Chicken breast
  • Tuna
  • Salmon
  • Peanuts
  • Mushrooms
  • Brown rice
  • Avocado
  • Sweet potato
  • Green peas

Incorporating these foods into your diet can help increase your niacin intake and prevent a deficiency.

Lifestyle Changes

Lifestyle changes can also help treat the Casal's Collar. Quitting smoking and limiting alcohol consumption can improve the absorption and utilization of niacin in the body.

Topical Creams

Topical creams containing niacin may also be used to treat the Casal's Collar. The patient can use topical treatments. These creams are applied directly to the affected area and can help improve the appearance of the pigmentation.

Follow-up Care

It is important to follow up with a healthcare provider after starting niacin supplementation to monitor the medical condition and ensure that the treatment is effective. Regular blood tests can also help monitor niacin levels in the body.


In conclusion, the Casal's Collari sign a clinical manifestation of pellagra, which is caused by a deficiency of niacin in the body. The condition can be prevented by incorporating niacin-rich foods into the diet, quitting smoking, and limiting alcohol consumption. Niacin supplementation and topical creams can also be used for the treatment of this medical condition.


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