Cutaneous manifestations of hepatitis B & C

Key Points

Pessac, France - The skin is said to be the mirror of what goes on in the body, and patients with internal disease will commonly present with cutaneous manifestations. Various dermatologic disorders are associated with viral hepatitis infections, and the unfortunate patient who contracts the virus will invariably present with skin symptoms, exposing the viral infection to the wary dermatologist.

According to Marie-Sylvie Doutre, M.D., chief of the department of dermatology, Haut-Leveque Hospital, Pessac, France, suspect cutaneous manifestations include cryoglobulinemia, infiltrated purpura, livedo reticularis and leg ulcers, and, less commonly, arthritis and neuropathies.

"Several diseases and their cutaneous manifestations are associated with hepatitis C virus infections, such as mixed cryoglobulinemia.

"We have found that hepatitis C virus RNA sequences are concentrated in the cryoprecipitate and are detected in the cutaneous lesions," Dr. Doutre tells Dermatology Times.

According to Dr. Doutre, the association of hepatitis C virus and cryoglobulinemia is a frequent occurrence, as anti-hepatitis C virus antibodies are detected in about 85 percent of cryoglobulinemia patients. Also, the efficacy of alpha interferon in about 50 percent of patients is also an argument for the role of hepatitis C virus in mixed cryoglobulinemia.

However, a clear relationship between hepatitis C virus infection and cryoglobulinemia has still not been established in respect to hepatitis C virus genotypes, viral load or genetic factors.

Dr. Doutre says that there have been some case reports of cutaneous vasculitis without cryoglobulinemia, but there has been a connection between hepatitis C virus infection and polyarteritis nodosa.

"Other links to hepatitis C virus infection and dermatologic disease include porphyria cutanea tarda. A high prevalence of hepatitis C virus markers - to the tune of 50 to 90 percent - have been reported in sporadic porphyria cutanea tarda patients in Italy, Spain and France. Other countries have shown lower rates of this association, but nonetheless, the rate of this association is significantly higher than in the corresponding general population," Dr. Doutre says.

She says that recently, there has been an increased frequency of hemochromatosis gene mutations detected in patients with sporadic porphyria cutanea tarda.

According to Dr. Doutre, this suggests that there is a synergistic action of genetic factors with extrinsic factors that lead to porphyria cutanea tarda disease manifestation.

Other dermatologic manifestations that have been weakly associated with hepatitis C virus infection include lichen planus and pruritus with concomitant nonspecific lesions, such as xerosis, excoriations and prurigo, as well as urticaria, erythema nodosum, erythema multiforme and necrolytic acral erythema.

"In patients with acute or chronic hepatitis B virus infections, dermatologic manifestations can also be seen such as urticaria, polyarteritis nodosa or Gianotti-Crosti Syndrome.

"During the preicteric phase of hepatitis B infection, urticarial lesions can commonly be associated with fatigue, headaches and arthralgias. These cutaneous urticarial lesions are not different from those of the common form of urticaria," Dr. Doutre says.

She says that in these urticarial lesions, a lymphocytic or leukocytoclastic vasculitis can be seen, and that hepatitis B antigen deposits can be observed in the small vessels.

According to Dr. Doutre, chronic urticaria is rarely associated with hepatitis B infection.

She says that the role of hepatitis B virus infection in mixed cryoglobulinemia is controversial. Hepatitis B virus markers can be observed in a high proportion of patients with type II or III cryoglobulins and hepatitis B antigens can be verified in the cryoprecipitate. However, according to Dr. Doutre, hepatitis B DNA is rarely demonstrated in these patients.

She says patients with hepatitis B virus infection can only be weakly linked with porphyria cutanea tarda or lichen planus symptoms, and that this relationship is very difficult to establish.

Dr. Doutre says hepatitis B virus markers are frequently associated with porphyria cutanea tarda, but hepatitis B antigens are only present in a few cases.

"Cutaneous reactions can occur during the treatment of hepatitis C or B infections. These reactions represent 5 to 17 percent of the side effects of the patients receiving interferon, 'classic' alpha-interferon or PEG-interferon, alone or in combination with ribavirin. The most common cutaneous symptoms that can occur include hair loss, pruritus and eczematous lesions," Dr. Doutre says.

"Most patients will clinically improve with interferon, but some will abandon the interferon treatment due to the adverse side effects," she says.

Dr. Doutre says vaccination with hepatitis B virus is effective and safe in adults and children; however, there are also various cutaneous side effects that can occur here as well, and that cutaneous reaction may be due to an individual predisposition.

Dermatologic symptoms that can occur following vaccination can include urticaria, angioedema, lichen planus, systemic and cutaneous leukocytoclastic vasculitis, polyarteritis nodosa and systemic lupus erythematosus.