Post on 21-Dec-2015
CUTANEOUS MANIFESTATIONS OF HEPATITIS B and C VIRUS
INFECTIONS
Marie-Sylvie DOUTRE
Bordeaux
(France)
Various dermatologic disorders are associated with viral hepatitis infections, sometimes revealing these infections.
The relation between HCV infection and some cutaneous manifestations is now clearly demonstrated
So, there are several arguments for the part of HVC in mixed cryoglobulinemia
HCV RNA sequencesare concentrated in the cryoprecipitate and detected in cutaneous lesions
Agnello Arthritis Rheum 1997
Dermatologic findings include infiltrated purpura,livedo reticularis, legs ulcers, sometimes associated with arthritis, neuropathy, nephropathy…
The efficacy of alpha interferon in about 50% of patient is also an argument for the role of HCV in mixed cryoglobulinemia
Sometimes, there are conflicting responses to treatment for liver and
cryoglobulinemia
The association HCV-cryoglobulinemia is frequent : anti-HCV antibodies are detected in about 85% of cryoglobulinemia
However, a clear relationship between HCV infection and cryoglobulinemia has not been etablished with
- HCV genotypes- viral load- genetic factors
HCV infection has also reported in case reports or small series of polyarteritis nodosa
Cacoub J Rheumatol 2001
High prevalence of HCV markers (50 to 90%) have been reported in sporadic PCT from Italy, Spain and France.Lower rates, but significant higher than in the corresponding general population, have been reported in other countries
Recently, an increased frequency of hemochromatosis gene mutations (C282Y, H63D) has been detected in patients with sporadic PCT, suggesting a synergistic action of genetic factors with extrinsec factors
Egger Dig Dis Sci 2002
For other dermatosis, some studies indicate a relationship, some others do not. So, the link between oral Lichen Planus
and HCV infection is always contreversial
Lodi Br J Dermatol 2004
Several factors contribute to the pruritus
- cholestasis- direct effect of HVC- treatments (interferon, ribavirin)
Fisher J Am Acad Dermatol 1994Cribier Acta Dermatol Venereol 1998
A lymphocytic sialadenitis does occur in patients with HCV infection
This is often associated with xerostomia but it is not associated with xerophtalmia or with anti SSA antibodies
Ramos- Casals Medicine 2005
Anecdotal dermatologic disorders have been reported in HCV infected patients
Urticaria
Erythema nodosum
Erythema multiform
Necrolytic acral erythemaAbdallah J Am Acad Dermatol 2005
Dermatological manifestions are also observed during acute and/or chronic phase of HBV infection
PARSONS Int J Dermatol 1996PYRSOPOULOUS Curr Gastroenterol Rep 2001
URTICARIA during the pre-icteric phase of HBV infection, association with fatigue, headache, arthralgia
DIENSTAG Ann Med Int 1978
There is a lymphocytic or leucocytoclastic vasculitis
HBs antigen deposits are observed in the small vesselsNEUMANN
Br J Dermatol 1981
cutaneous vasculitis can be associated with arthralgia, renal or neurological manifestations
vasculitis can occur during acute or chronic phase of HBV infection
SERGENT Medicine 1976
The role of HBV in mixed cryoglobulinemia is contreversial HBV markers are observed in high
proportions of patients with type II or III cryoglobulins LEVO N Engl J Med 1977
HBs antigen is present in the cryoprecipitate
However, HBV DNA is rarely demonstrated in these patientsCACOUB Arthritis Rheum 1992
POLYARTERITIS NODOSA
In the seventies, the prevalence was estimated to be 30 to 40 %, at present, about 7 %
Mouthon Pathol Biol 1999 Trepo Autoimmun 2001
the cutaneous manifestations are similar
some manifestations are more common in HBV related PAN : abdominal signs, renal failure, arterial hypertension, orchitis
mortality is not different in two types of PAN
Guillevin J Int Med 1989
treatment is different with short course of steroid therapy, plasma exchanges and anti viral drugs
Guillevin J Rheumatol 1989
GIANOTTI-CROSTI syndromeThe role of HBV infection was discovered in the seventies
GIANOTTI Br J Dermatol 1970
The eruption is associated with an anicteric hepatitis
CAPUTO J Am Acad Dermatol 1992
in fact, many different virus can be associated with this eruption (EBV, HBC, CMV, adenovirus, HHV-6...)
CHUH Pediatr Dermatol 2002TERASAKI Dermatology 2003
LICHEN PLANUS
The link between L.P. and chronic hepatitis has been etablished.REBORA Int J Dermatol 1984
The frequency of HBV markers is between 4 to 40 % but the replication of HBV was not demonstrated
At present, the link between L.P. and HBV infection is difficult to etablish
>> all studies were published when serological detection of HVC was not available
PORPHYRIA CUTANEA TARDAHBV markers are frequently associated with PCT but HBs antigen was
present in only few casesROCCHI Liver 1986 VALLS J Dermatol 1986
the series were published before the serological tests for HCV are available
OTHER TYPES OF CUTANEOUS ERUPTION ARE OBSERVED
photolocalized eruption
KAYAKAWA Br J Dermatol 1996
papular purpuric gloves and socks
GUIBAL Lancet 1996
Some cutaneous manifestations can appear during the treatment
of viral infection
Cutaneous reactions represent 5 to 17 % of side effects observed in patients receiving Interferon, «classic» alpha INF or peg-interferon, alone or in combination with ribavirin
DALEKOS Eur J Gastroenterol Hepatol 1998
Hair loss, itching, xerosis and eczematous lesions are the most frequent adverse cutaneous manifestations
Sookoian Arch Dermatol 1999Manjon-Haces Acta Derm Venereol2001Kerl Br J Dermatol 2003
Most patients showed clinical improvement with symptomatic treatment.
However, some patients abandoned nterferon because of these side-effects
Dereure Br J Dermatol 2002
Induction or exacerbation of psoriasis, lupus, lichen, vitiligo, autoimmune bullous dermatosis has been also described
Georgetson Am J Gastroenterol 1993Doutre Gastroenterol
Clin Biol 1996
Others cutaneous side-effects are also reported here and there Straightening of hair Bessis Br J Dermatol 2002
Lanigan Br J Dermatol 2003
Meyerson’s phenomenomKrischer J Am Acad Dermatol 1999
Girard Br J Dermatol 2005
Skin and cutaneous hyperpigmentation Willems Br J Dermatol 2003
Much less frequently, necrosis is observed, no dependent on the site of injection or the dose
The exact mechanismsremain unknown
The extension of HB vaccination has led to the appearance of dermatologic side effects
The tolerance of HB vaccine is generally good.However, some dermatologic manifestations have been observed in children and adults.
MAC MAHON Am J Med 1992 AUBIN Rev Fr Allergol 1994
urticaria and angiooedema BARBAUD Br J Dermatol 1998
lichen planus Numerous observations in the literature since the first case
reported in 1990 by CIACCIO and REBORA
systemic and cutaneous leucocytoclastic vasculitis Some thirty cases in the literature
polyarteritis nodosa DE FAYSER Clin Exp Rheumatol 2000 BOURGEAIS Ann Dermatol Venereol 2003
systemic lupus erythematosus TUDELA Nephron 1992 MAMOUX Arch Pediatr 1994 GUISERIX Nephron 1996 FINIELZ Nephrol Dial Transplant 1998
Other manifestations are observed more rarely
Generalized granuloma annulare WOLF Eur J Dermatol 1998
Erythema multiform WAKEEL Br J Dermatol 1992 LOCHE Clin Exp Dermatol 2000
Erythema nodosum DI GIUSTO Lancet 1986 GOOLSBY N Engl J Med 1989
cutaneous lupus erythematosus and buccal aphtosis GREZARD Ann Dermatol Venereol 1996
pityriasis rosea like-eruption DE KEYSER Clin Exp Rheumatol 2000
Gianotti-Crosti syndrome HANG Hautartz 2002
For these adverse reactions, it is still debated whether there is a causal association or a simple coincidence.
"Sequence is not consequence"
CALES Gastroenterol Clin Biol 2001
Reactions are also described at the injection site. They are usually transient, erythema, itching, oedema.
COSNES Contact dermatitis 1990
KAABER Contact dermatitis 1992
SKOWRON Contact dermatitis 1997
Sometimes, painful erythematosus nodules apparead, due to aluminium
Other local reactions are observed
localized lichenoid reaction due to thiomersal STAURIANEAS Dermatology 2002
lipoatrophy VILETTE Ann Dermatol Venereol 1997
necrobiotic granuloma AJITHKUMAR Clin Exp Dermatol 1998
Considering the very low proportion of affected patients in comparaison with all subjects immunized (in France, 27 millions in 1998), an individual predisposition seems very likely.
Vaccination with HBV is effective and safe