Necrolytic Acral Erythema Associated with Chronic Hepatitis C: A Case Report

Abstract

Necrolytic acral erythema (NAE) is an uncommon clinicopathological dermatosis strongly associated with chronic hepatitis C virus (HCV) infection and frequently linked to abnormalities in zinc metabolism. It typically presents as a symmetrical acral eruption over the dorsa of the feet, evolving from erythematous papules to hyperkeratotic, hyperpigmented scaly plaques, with histopathology showing psoriasiform epidermal hyperplasia and focal necrolytic changes. We report a case of a 45-year-old man who presented with painful, pruritic lesions over both feet for six months. Cutaneous examination revealed bilaterally symmetrical, well-defined hyperpigmented plaques with thick adherent dark scales and peripheral erythema over the dorsae of the feet and toes, with sparing of the palms, soles, nails, and mucosa. Laboratory investigations showed low serum zinc levels of 45 mcg/dL, positive HCV serology, and HCV RNA viral load of 2.5 million IU/mL, along with mildly elevated liver transaminases. Histopathological examination of a lesional skin biopsy demonstrated psoriasiform epidermal hyperplasia, focal parakeratosis, pallor of the upper epidermis, scattered necrotic keratinocytes, and mild superficial perivascular lymphocytic infiltrate, confirming the diagnosis of NAE. The patient was treated with oral zinc sulfate 220 mg three times daily and showed significant clinical improvement within four weeks, with marked reduction in erythema, scaling, and plaque thickness. This case highlights the importance of recognizing NAE as a cutaneous marker of underlying HCV infection and zinc deficiency, enabling timely diagnosis and appropriate management.