Medical Care

The optimal treatment for necrolytic acral erythema (NAE) is the optimal treatment of hepatitis C—combination therapy with interferon and ribavirin. In one patient, ribavirin in addition to the interferon-alfa therapy improved the necrolytic acral erythema despite the presence of a continued high viral load.^[27]In a study by El-Ghandour et al, interferon-alfa combined with ribavirin given to four patients caused regression of the plaques of necrolytic acral erythema in three patients and complete clearance in one patient.^[21]Interferon-alfa monotherapy has been reported to be effective treatment.^[33]A 2017 review of the literature noted a case report describing treatment of hepatitis C with sofosbuvir and ledipasvir that resulted in clearance of necrolytic acral erythema from the skin.^[34]This report has not yet been noted by others, yet it is promising.

Patients have been responsive to oral zinc supplementation in several cases.^{[9, 29, 35, 36]}Oral zinc supplements can be effective in patients with normal serum zinc levels.^{[6, 9, 35]}In two cases, the combination of oral zinc and interferon-alfa therapy resulted in total clearance.^{[1, 33]}Zinc supplementation has been shown to enhance the effects of hepatitis C treatment.^[37]

Amino acid replacement therapy, both orally and parenterally, has yielded some improvement.^{[8, 13]}

One report noted the use of cetirizine, oral zinc, topical tacrolimus, and salicylic acid with success.^[32]

Disease response to corticosteroid therapy (ie, topical, intralesional, and systemic) has been poor. No benefit has been seen with topical tar or tetracycline.

Surgical Care

A surgical approach has not been shown to be therapeutically beneficial.

Consultations

Consultation with an infectious disease specialist, gastroenterologist, or hepatologist may be helpful for management of the hepatitis C. Consultation with a dermatologist may be helpful for diagnosis and management of cutaneous findings.

Diet

Supplementation with zinc and amino acids has shown benefit.

Activity

No restrictions on activity are needed for persons with this condition.

Prevention

Preventing hepatitis C is the primary prevention for necrolytic acral erythema (NAE).

Medication

el Darouti M, Abu el Ela M. Necrolytic acral erythema: a cutaneous marker of viral hepatitis C. Int J Dermatol. 1996 Apr. 35(4):252-6. [QxMD MEDLINE Link].
Tabibian JH, Gerstenblith MR, Tedford RJ, Junkins-Hopkins JM, Abuav R. Necrolytic Acral Erythema as a Cutaneous Marker of Hepatitis C: Report of Two Cases and Review. Dig Dis Sci. 2010 May 26. [QxMD MEDLINE Link].
Abdallah MA, Ghozzi MY, Monib HA, et al. Necrolytic acral erythema: a cutaneous sign of hepatitis C virus infection. J Am Acad Dermatol. 2005 Aug. 53(2):247-51. [QxMD MEDLINE Link].
Frank C, Mohamed MK, Strickland GT, Lavanchy D, Arthur RR, Magder LS, et al. The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet. 2000 Mar 11. 355 (9207):887-91. [QxMD MEDLINE Link].
Wu YH, Tu ME, Lee CS, Lin YC. Necrolytic acral erythema without hepatitis C infection. J Cutan Pathol. 2009 Mar. 36(3):355-8. [QxMD MEDLINE Link].
Srisuwanwattana P, Vachiramon V. Necrolytic Acral Erythema in Seronegative Hepatitis C. Case Rep Dermatol. 2017 Jan-Apr. 9 (1):69-73. [QxMD MEDLINE Link].
Liu A, Erickson CP, Cockerell CJ, Hsu S. Necrolytic acral erythema: a case not associated with hepatitis C infection. Dermatol Online J. 2008 Jun 15. 14 (6):10. [QxMD MEDLINE Link].
Jakubovic BD, Zipursky JS, Wong N, McCall M, Jakubovic HR, Chien V. Zinc deficiency presenting with necrolytic acral erythema and coma. Am J Med. 2015 Aug. 128 (8):e3-4. [QxMD MEDLINE Link].
Ghosh A, Aggarwal I, De A, Samanta A, Chatterjee G, Bala S, et al. Zinc-responsive acral hyperkeratotic dermatosis-A novel entity or a subset of some well-known dermatosis?. Indian J Dermatol. 2015 Mar-Apr. 60 (2):136-41. [QxMD MEDLINE Link].
Garcovich S, Garcovich M, Capizzi R, Gasbarrini A, Zocco MA. Cutaneous manifestations of hepatitis C in the era of new antiviral agents. World J Hepatol. 2015 Nov 28. 7 (27):2740-8. [QxMD MEDLINE Link].
El-Darouti MA, Mashaly HM, El-Nabarawy E, et al. Leukocytoclastic vasculitis and necrolytic acral erythema in patients with hepatitis C infection: do viral load and viral genotype play a role?. J Am Acad Dermatol. 2010 Aug. 63(2):259-65. [QxMD MEDLINE Link].
Raphael BA, Dorey-Stein ZL, Lott J, Amorosa V, Lo Re V 3rd, Kovarik C. Low prevalence of necrolytic acral erythema in patients with chronic hepatitis C virus infection. J Am Acad Dermatol. 2012 Feb 9. [QxMD MEDLINE Link].
Woldow A, Manton JS, Campanelli C, Ringpfeil F. The necrolytic erythemas: a continuous spectrum?. Cutis. 2011 Oct. 88:185-8. [QxMD MEDLINE Link].
Panda S, Lahiri K. Seronegative necrolytic acral erythema: a distinct clinical subset?. Indian J Dermatol. 2010 Jul-Sep. 3:259-61. [QxMD MEDLINE Link].
Patel U, Loyd A, Patel R, Meehan S, Kundu R. Necrolytic acral erythema. Dermatol Online J. 2010 Nov. 11:15. [QxMD MEDLINE Link].
Ko HM, Hernandez-Prera JC, Zhu H, Dikman SH, Sidhu HK, Ward SC, et al. Morphologic features of extrahepatic manifestations of hepatitis C virus infection. Clin Dev Immunol. 2012:. 2012;:740138. [QxMD MEDLINE Link].
Nofal AA, Nofal E, Attwa E, El-Assar O, Assaf M. Necrolytic acral erythema: a variant of necrolytic migratory erythema or a distinct entity?. Int J Dermatol. 2005 Nov. 44(11):916-21. [QxMD MEDLINE Link].
Moneib HA, Salem SA, Darwish MM. Evaluation of zinc level in skin of patients with necrolytic acral erythema. Br J Dermatol. 2010 Sep. 163 (3):476-80. [QxMD MEDLINE Link].
Ogawa Y, Kawamura T, Shimada S. Zinc and skin biology. Arch Biochem Biophys. 2016 Dec 1. 611:113-119. [QxMD MEDLINE Link].
Pernet C, Guillot B, Araka O, Dereure O, Bessis D. Necrolytic acral erythema following hepatitis B vaccination. Br J Dermatol. 2014 Nov. 171(5):1255-6. [QxMD MEDLINE Link].
El-Ghandour TM, Sakr MA, El-Sebai H, El-Gammal TF, El-Sayed MH. Necrolytic acral erythema in Egyptian patients with hepatitis C virus infection. J Gastroenterol Hepatol. 2006 Jul. 21(7):1200-6. [QxMD MEDLINE Link].
Yost JM, Boyd KP, Patel RR, Ramachandran S, Franks AG Jr. Necrolytic acral erythema. Dermatol Online J. 2013 Dec. 16;19(12):20709. [QxMD MEDLINE Link].
Williams J. Necrolytic acral erythema. DermAtlas. Available at http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=178630456. Accessed: January 25, 2007.
Xiaoling Y, Hongzhong J, Tao Q. Image Gallery: Seronegative necrolytic acral erythema. Br J Dermatol. 2018 Aug. 179 (2):e88. [QxMD MEDLINE Link].
Pakistan Society of Teledermatology, Janjua S. Necrolytic acral erythema. Pakistan Society of Teledermatology. Available at http://paktelederm.blogspot.com/2012/12/how-would-you-treat-this-patient_23.html. Accessed: Feburary 8, 2013.
Abdallah MA, Ghozzi MY, Monib HA, et al. Histological study of necrolytic acral erythema. J Ark Med Soc. 2004 Apr. 100(10):354-5. [QxMD MEDLINE Link].
Hivnor CM, Yan AC, Junkins-Hopkins JM, Honig PJ. Necrolytic acral erythema: response to combination therapy with interferon and ribavirin. J Am Acad Dermatol. 2004 May. 50(5 Suppl):S121-4. [QxMD MEDLINE Link].
Iyengar S, Chang S, Ho B, Fung M, Konia TH, Prakash N, et al. Necrolytic acral erythema masquerading as cellulitis. Dermatol Online J. 2014 Nov 15. 20(11):[QxMD MEDLINE Link].
Najarian DJ, Lefkowitz I, Balfour E, Pappert AS, Rao BK. Zinc deficiency associated with necrolytic acral erythema. J Am Acad Dermatol. 2006 Nov. 55(5 Suppl):S108-10. [QxMD MEDLINE Link].
Najarian DJ, Najarian JS, Rao BK, Pappert AS. Hypozincemia and hyperzincuria associated with necrolytic acral erythema. Int J Dermatol. 2008 Jul. 47(7):709-11. [QxMD MEDLINE Link].
Bentley D, Andea A, Holzer A, Elewski B. Lack of classic histology should not prevent diagnosis of necrolytic acral erythema. J Am Acad Dermatol. 2009 Mar. 60(3):504-7. [QxMD MEDLINE Link]. [Full Text].
Hayat W, Zahra K, Mahmood LM, Ali Azfar N, Mohammed J. Necrolytic acral erythema: an unusual cutaneous presentation of hepatitis C virus infection. J Pakistan Asso Dermatol. 2012. 22:66-9.
Khanna VJ, Shieh S, Benjamin J, et al. Necrolytic acral erythema associated with hepatitis C: effective treatment with interferon alfa and zinc. Arch Dermatol. 2000 Jun. 136(6):755-7. [QxMD MEDLINE Link].
Wiznia LE, Laird ME, Franks AG Jr. Hepatitis C virus and its cutaneous manifestations: treatment in the direct-acting antiviral era. J Eur Acad Dermatol Venereol. 2017 Aug. 31 (8):1260-1270. [QxMD MEDLINE Link].
Abdallah MA, Hull C, Horn TD. Necrolytic acral erythema: a patient from the United States successfully treated with oral zinc. Arch Dermatol. 2005 Jan. 141(1):85-7. [QxMD MEDLINE Link].
de Carvalho Fantini B, Matsumoto FY, Arnone M, Sotto MN, Junior WB. Necrolytic acral erythema successfully treated with oral zinc. Int J Dermatol. 2008 Aug. 47(8):872-3. [QxMD MEDLINE Link].
Takagi H, Nagamine T, Abe T, Takayama H, Sato K, Otsuka T, et al. Zinc supplementation enhances the response to interferon therapy in patients with chronic hepatitis C. J Viral Hepat. 2001 Sep. 8 (5):367-71. [QxMD MEDLINE Link].
Manzur A, Siddiqui AH. Necrolytic acral erythema: successful treatment with topical tacrolimus ointment. Int J Dermatol. 2008 Oct. 47(10):1073-5. [QxMD MEDLINE Link].

Media Gallery

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

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Author

Fnu Nutan, MD, FACP Assistant Professor, Department of Dermatology, Virginia Commonwealth University School of Medicine

Fnu Nutan, MD, FACP is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, Indian Association of Dermatologists, Venereologists and Leprologists, Society of General Internal Medicine, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Julie Zixuan Yi MD Candidate, Eastern Virginia Medical School

Julie Zixuan Yi is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Timothy McCalmont, MD Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, United States and Canadian Academy of Pathology

Disclosure: Received consulting fee from Apsara for independent contractor.

Noah S Scheinfeld, JD, MD, FAAD † Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Katherine Z Holcomb, MD, MPH Dermatologist, Lupo Center for Aesthetic and General Dermatology; Clinical Assistant Professor, Department of Derrmatolgy, Tulane University School of Medicine

Katherine Z Holcomb, MD, MPH is a member of the following medical societies: American Academy of Dermatology, American Contact Dermatitis Society, American Society for Dermatologic Surgery, Louisiana Dermatological Society, Women's Dermatologic Society

Disclosure: Nothing to disclose.