Necrolytic Acral Erythema Clinical Presentation

Updated: Jun 25, 2020
  • Author: Fnu Nutan, MD, FACP; Chief Editor: Dirk M Elston, MD  more...
  • Print


Patients with necrolytic acral erythema (NAE) present with a 1-month to 2-year history of a rash, usually on the dorsum of the feet or the hands. In many cases, it has been unresponsive to topical steroids. Itching can precede the development of the rash.

Patients do not necessarily give a history of hepatitis C. Necrolytic acral erythema may be the presenting sign. Patients may report a burning sensation, especially when walking or standing. Sometimes, necrolytic acral erythema lesions are pruritic or express purulent drainage. The most common area of origin of the rash is the dorsal aspect of the great toe. It also occurs on the shins. In 43 of 44 reported cases, necrolytic acral erythema did not affect the palms or soles, nail bed, nail plate, or mucous membranes.

Williams [23] reported a case of necrolytic acral erythema in an adolescent boy with a history of infection with hepatitis C virus; he had hepatic fibrosis, hypertension, and thrombocytopenia. The patient developed a pruritic eruption on his face, trunk, genitals, and extremities, and the eruption had a predilection for bony prominences. This patient did not respond to topical steroids, antihistamines, topical barrier repair creams, narrow-band UV-B therapy, or tar baths. A skin biopsy specimen demonstrated a nonspecific psoriasiform dermatitis consistent with necrolytic acral erythema. Hepatitis C virus RNA polymerase chain reaction studies showed 974,000 IU/mL (< 50) and hepatitis C virus RNA genotype 1b.


Physical Examination

Dusky, red erythematous plaques are present bilaterally on the dorsum of the feet and toes. In 2018, an image gallery of pictures of necrolytic acral erythema (NAE) was published. [24] Lesions may extend around to the skin overlying the Achilles tendon and up the lower leg, as depicted in the image below.

Plaque of necrolytic acral erythema on the ankle o Plaque of necrolytic acral erythema on the ankle of a male.

A key finding of necrolytic acral erythema is that while the plaques have a psoriatic morphology, they do not show the psoriasis Auspitz sign (ie, if you pick at the scale, it does not bleed). [25] Active necrolytic acral erythema has different symptoms from psoriasis. The plaques of psoriasis itch, and the plaques of necrolytic acral erythema can express burning or pruritus. Usually, lesions do not occur on the trunk as in psoriasis. Necrolytic acral erythema is an all-acral disease. Some necrolytic acral erythema patients have zinc dysregulation and not hepatitis C infection, showing the complexity of the disease.

The dorsum of the hands may or may not be involved. The lesions are clearly demarcated from uninvolved skin by a dark red border. The surface may be scaly, eroded, or velvety. Thick hyperkeratosis is sometimes present. Active lesions often include flaccid blisters. Edema may or may not be present.

Abdallah et al [26] describe the following stages of the lesions:

  1. Initial stage: Erythematous papules or plaque with scale are present and have a dusky or eroded center.

  2. Fully developed stage: A confluence of papules and plaques with sharply defined margins and adherent scale develops. Increased hyperpigmentation and decreased redness may be present. Lesions may be lichenified. Pustules also may occur at this stage.

  3. Late stage: Thinning of lesions occurs, with continued hyperpigmentation. Demarcation continues, followed by spontaneous relapse and remission.

As a general rule, necrolytic acral erythema does not affect the palms or soles, the nail bed, nail plate, or mucous membranes. Hivnor et al [27] reported a single case in which the plaques extended proximally to the thighs. This patient also had hyperkeratosis of the palms and soles and involvement of the face. While multiple biopsy specimens confirmed necrolytic acral erythema histologically, it is not clear whether these biopsy specimens were taken from the typical locations of necrolytic acral erythema or if the palms and soles were also included in the biopsy specimen.

Other disorders that can be seen in persons with hepatitis C should be considered as possible epiphenomena. These include the following:



The complications of necrolytic acral erythema (NAE) are cosmetic. Resolution of the active lesions often leaves postinflammatory pigmentary alteration.