Low prevalence of necrolytic acral erythema in patients with chronic hepatitis C virus infection

Abstract

Background: Chronic hepatitis C virus (HCV) infection is associated with necrolytic acral erythema (NAE). However, the prevalence of NAE among patients with HCV is unknown, and the clinical and histologic features have not been well defined.

Objective: We sought to determine the prevalence, overall clinical features, and cutaneous histopathological characteristics of patients with NAE.

Methods: A cross-sectional study was performed among patients with chronic HCV infection cared for at 3 Philadelphia hospitals. Patients completed a questionnaire and underwent a dermatologic examination. All undiagnosed skin lesions with clinical features of NAE as described in the literature underwent skin biopsy.

Results: Among 300 patients with chronic HCV infection (median age 55 years; 73% male; 70% HCV genotype 1), 5 of them (prevalence 1.7%; 95% confidence interval 0.5%-3.8%) had skin lesions consistent with NAE clinically, which were analyzed and confirmed with skin biopsy specimen. All 5 skin biopsy specimens demonstrated variable psoriasiform hyperplasia, mild papillomatosis, parakeratosis, and necrotic keratinocytes in the superficial epidermis. All 5 patients were older than 40 years, were African American men, were infected with HCV genotype 1, and had a high viral load (>200,000 IU/mL).

Limitations: Previous descriptions of NAE were used to guide the evaluation and need for a biopsy; however, other unknown clinical characteristics of the disease may exist. The senior author was the sole interpreter of the biopsy specimens. Only 300 of the 2500 eligible patients enrolled in the study.

Conclusion: The prevalence of NAE among patients with chronic HCV in this sample was very low. Further research is needed to determine the origin and appropriate therapies of NAE.

Figure 1

Necrolytic Acral Erythema. Well defined dusky, hyperkerototic plaques on the shin and dorsal foot of a patient with necrolytic acral erythema (NAE).

Figure 1

Necrolytic Acral Erythema. Well defined dusky, hyperkerototic plaques on the shin and dorsal foot of a patient with necrolytic acral erythema (NAE).

Figure 2

Necrolytic Acral Erythema. Histopathology of punch biopsy from a hyperkeratotic plaque showing papillomatosis, necrosis of keratinocytes within the very superficial epidermis,vascular ectasia within the dermal papillae, and a patchy lymphocytic infiltrate. Original magnification X100 (A) and X200 (B)

Figure 2

Necrolytic Acral Erythema. Histopathology of punch biopsy from a hyperkeratotic plaque showing papillomatosis, necrosis of keratinocytes within the very superficial epidermis,vascular ectasia within the dermal papillae, and a patchy lymphocytic infiltrate. Original magnification X100 (A) and X200 (B)