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Necrolytic acral erythema in seronegative hepatitis C patient with vitamin B12 deficiency

 Department of Dermatology, Command Hospital, Bengaluru, Karnataka, India

Date of Web Publication24-Jan-2020

Correspondence Address:
Richa Kumar,
Department of Dermatology, Command Hospital Airforce, Bengaluru - 560 007, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/idoj.IDOJ_398_19

How to cite this URL:
Kumar R, Arora S, Ranjan E, Das N. Necrolytic acral erythema in seronegative hepatitis C patient with vitamin B12 deficiency. Indian Dermatol Online J [Epub ahead of print] [cited 2020 Feb 19]. Available from: http://www.idoj.in/preprintarticle.asp?id=276581


Necrolytic acral erythema (NAE) is an important cutaneous diagnostic marker for hepatitis C infection (HCV).[1] It has also been described with low serum zinc levels.[2] Cases of NAE in seronegative Hepatitis C with normal zinc levels and Vitamin B12 deficiency are rare in the literature, which led to the present report.

Our patient, a 40-year-old female presented with complaints of dark-colored itchy lesions over both the feet of 08 months duration with the absence of similar scaly lesions over hands or elsewhere on the body. Dermatological examination revealed sharply defined, bilaterally symmetrical, nontender, hyperpigmented scaly plaques with distinct marginal erythema over the dorsal aspect of both feet extending to the distal end of toes [Figure 1]. Differential diagnosis of chronic plaque psoriasis, allergic contact dermatitis to slippers, and tinea pedis were considered; however, Grattage test and Auspitz sign were negative, patch test to standard Indian Series Battery was negative, and KOH mount for fungal hyphae was negative for fungal elements. On investigations, her Vitamin B12 levels were found to be 130 pg/ml (normal 187–883 pg/ml) with normal zinc levels. The patient was seronegative for HCV infection. All other hematological and biological parameters were within normal limits. Histopathological findings were consistent with NAE: hyperkeratosis, focal papillomatosis, variable acanthosis, spongiosis, and scattered individual keratinocyte necrosis. Pigment incontinence along with mild lymphocytic infiltrate was present. [Figure 2]. She was started on Vitamin B12 supplementation 1500 mcg orally for 06 months with an initial application of Beclomethasone (0.1%) + Salicylic Acid (3%) for symptomatic relief from itching for 02 weeks. The patient showed good response to therapy with reduction in erythema, scaling, and induration in that order over the next 5 months [Figure 3]. She was administered an additional 1 month of vitamin B12 and then discontinued. She continues to be asymptomatic 6 months later.
Figure 1: Sharply defined, bilaterally symmetrical, hyperpigmented scaly plaques with distinct marginal erythema over the dorsal aspect of both feet extending to the distal end of toes

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{Figure 2}
Figure 3: Good response to therapy with reduction in erythema, scaling and induration

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NAE belongs to the group of necrolytic erythemas with unknown pathogenesis. However, it is thought to be related to zinc dysregulation, which can occur due to HCV-induced metabolic alteration.[3] This condition is associated with decreased zinc levels in both the serum and the skin. Other causes such as metabolic alterations including hypoalbuminemia, hypoaminoacidemia, hyperglucagonemia, liver dysfunction, and diabetes have been proposed.[4] NAE is classically located at the acral sites, characterized by hyperpigmented plaques with clear border of erythema. Treatment in the literature ranges from oral zinc supplementation to antiviral therapy for HCV (Interferon-alpha with or without ribavirin).[5] Limited number of cases have been described with hepatitis C seronegative status and normal zinc levels [Table 1].[3],[4],[5],[6],[7],[8] We did not come across any case of association of NAE with Vit B12 deficiency in the literature which makes our case interesting.
Table 1: Review of seronegative necrolytic acral erythema

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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   References Top

el Darouti M, Abu el Ela M. Necrolytic acral erythema: A cutaneous marker of viral hepatitis C. Int J Dermatol 1996;35:252-6.  Back to cited text no. 1
Moneib HA, Salem SA, Darwish MM. Evaluation of zinc level in skin of patients with necrolytic acral erythema. Br J Dermatol 2010;163:476-80.  Back to cited text no. 2
Srisuwanwattana P, Vachiramon V. Necrolytic acral erythema in seronegative hepatitis C. Case Rep Dermatol 2017;9:69-73.  Back to cited text no. 3
Das A, Kumar P, Gharami RC. Necrolytic acral erythema in the absence of hepatitis C virus infection. Indian J Dermatol 2016;61:96-9.  Back to cited text no. 4
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Pandit VS, Inamadar AC, Palit A. Seronegative necrolytic acral erythema: A report of two cases and literature review. Indian Dermatol Online J 2016;7:304-7.  Back to cited text no. 5
[PUBMED]  [Full text]  
Wu YH, Tu ME, Lee CS, Lin YC. Necrolytic acral erythema without hepatitis C infection. J Cutan Pathol 2009;36:355-8.  Back to cited text no. 6
Nikam BP. Necrolytic acral erythema seronegative for hepatitis C virus - two cases from India treated with oral zinc. Int J Dermatol 2009;48:1096-9.  Back to cited text no. 7
Panda S, Lahiri K. Seronegative necrolytic acral erythema: A distinct clinical subset? Indian J Dermatol 2010;55:259-61.  Back to cited text no. 8
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  [Figure 1], [Figure 5], [Figure 3]

  [Table 1]


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