Digestive Diseases and Sciences

, Volume 55, Issue 10, pp 2735-2743

First online:

Necrolytic Acral Erythema as a Cutaneous Marker of Hepatitis C: Report of Two Cases and Review

  • James H. TabibianAffiliated withDepartment of Medicine, Johns Hopkins Hospital Email author 
  • , Meg R. GerstenblithAffiliated withDepartment of Dermatology, Johns Hopkins Hospital
  • , Ryan J. TedfordAffiliated withDepartment of Medicine, Johns Hopkins Hospital
  • , Jacqueline M. Junkins-HopkinsAffiliated withDepartment of Pathology, Johns Hopkins Hospital
  • , Rachel AbuavAffiliated withDepartment of Dermatology, Johns Hopkins Hospital

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Necrolytic acral erythema (NAE) is a member of the necrolytic erythemas, which include necrolytic migratory erythema (NME), acrodermatitis enteropathica, and various dermopathies secondary to nutritional deficiencies. NAE is distinct from the other necrolytic erythemas by virtue of its consistent association with hepatitis C (HCV) together with the acral distribution of its lesions, in particular, dorsal hands and feet. Although its etiology is unknown, NAE has been reported to respond to zinc replacement, suggesting a causal relationship. Two patients with HCV infection presented with scaly acral plaques and histopathologic features consistent with NAE while also demonstrating atypical palmoplantar accentuation of lesions. Both patients were found to have zinc deficiency, and their lesions responded to zinc supplementation. Awareness of NAE as a unique cutaneous marker for HCV infection is important not only for accurate dermatologic diagnosis but also for appropriate management of associated morbidity and prompt detection of potentially undiagnosed underlying HCV.


Necrolytic acral erythema Hepatitis C Zinc Malnutrition Rash