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An 18-Month History of Dorsal Foot Lesions

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 32-year-old Nigerian woman presented with dull pain, pruritus, and discoloration of the dorsal aspect of both feet for 18 months. Her medical history included a red blood cell transfusion as a child and 2 uncomplicated pregnancies.

The lesions started as small papules on the dorsal right great toe and left third toe that gradually spread across the dorsum of her feet over the following 12 months. An over-the-counter antifungal ointment was unhelpful. Her primary care physician completed a biopsy, diagnosed verruca plantaris, and prescribed topical salicylic acid twice daily for 4 weeks. The lesions did not improve, and her foot pain worsened. Subsequent treatment with topical liquid nitrogen cryotherapy was ineffective.

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Hepatitis C–induced necrolytic acral erythema (NAE)

D. Prescribe oral zinc therapy

The keys to the correct diagnosis in this case were the childhood history of a red blood cell transfusion associated with acquisition of HCV, the dorsal distribution of lesions, and intraepidermal necrosis on the biopsy.1,2 In patients with hepatitis C–induced NAE, the combination of hypertrophic verrucous plaques and microscopic findings of psoriasiform hyperplasia commonly result in the misdiagnosis of psoriasis, eczematous dermatitis, or hypertrophic lichen planus.3 Because the punch biopsy provided diagnostic information, an incisional biopsy (choice A) was not required. Additionally, the case offers no clinical indications for the use of antibiotics (choice B) or further imaging (choice C).

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Article Information

Corresponding Author: Gordon T. Moffat, MD, Department of Medicine, State University of New York Downstate Health Sciences University, 450 Clarkson Ave, MSC 50, Brooklyn, NY 11203 (Gordon.moffat@downstate.edu).

Published Online: January 15, 2021. doi:10.1001/jama.2020.16053

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Jessica Maloh, BSc, Canadian College of Naturopathic Medicine, for contributing to this article. Ms Maloh did not receive any compensation for her contributions. We thank the patient for providing permission to share her information.

References
1.
Abdallah  MA , Ghozzi  MY , Monib  HA ,  et al.  Necrolytic acral erythema: a cutaneous sign of hepatitis C virus infection.   J Am Acad Dermatol. 2005;53(2):247-251. doi:10.1016/j.jaad.2005.04.049PubMedGoogle ScholarCrossref
2.
Khanna  VJ , Shieh  S , Benjamin  J ,  et al.  Necrolytic acral erythema associated with hepatitis C.   Arch Dermatol. 2000;136(6):755-757. doi:10.1001/archderm.136.6.755PubMedGoogle ScholarCrossref
3.
el Darouti  M , Abu el Ela  M .  Necrolytic acral erythema: a cutaneous marker of viral hepatitis C.   Int J Dermatol. 1996;35(4):252-256. doi:10.1111/j.1365-4362.1996.tb02997.xPubMedGoogle ScholarCrossref
4.
Blach  S , Zeuzem  S , Manns  M ,  et al; Polaris Observatory HCV Collaborators.  Global prevalence and genotype distribution of hepatitis C virus infection in 2015.   Lancet Gastroenterol Hepatol. 2017;2(3):161-176. doi:10.1016/S2468-1253(16)30181-9PubMedGoogle ScholarCrossref
5.
Raphael  BA , Dorey-Stein  ZL , Lott  J , Amorosa  V , Lo Re  V  III , Kovarik  C .  Low prevalence of necrolytic acral erythema in patients with chronic hepatitis C virus infection.   J Am Acad Dermatol. 2012;67(5):962-968. doi:10.1016/j.jaad.2011.11.963PubMedGoogle ScholarCrossref
6.
Srisuwanwattana  P , Vachiramon  V .  Necrolytic acral erythema in seronegative hepatitis C.   Case Rep Dermatol. 2017;9(1):69-73. doi:10.1159/000458406PubMedGoogle ScholarCrossref
7.
Tabibian  JH , Gerstenblith  MR , Tedford  RJ ,  et al.  Necrolytic acral erythema as a cutaneous marker of hepatitis C.   Dig Dis Sci. 2010;55(10):2735-2743. doi:10.1007/s10620-010-1273-7PubMedGoogle ScholarCrossref
8.
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;50(5)(suppl):S121-S124. doi:10.1016/j.jaad.2003.09.017PubMedGoogle ScholarCrossref
9.
Moneib  HAM , Salem  SAM , Darwish  MM .  Evaluation of zinc level in skin of patients with necrolytic acral erythema.   Br J Dermatol. 2010;163(3):476-480. doi:10.1111/j.1365-2133.2010.09820.xPubMedGoogle ScholarCrossref
10.
Wiznia  LE , Laird  ME , Franks  AG  Jr .  Hepatitis C virus and its cutaneous manifestations.   J Eur Acad Dermatol Venereol. 2017;31(8):1260-1270. doi:10.1111/jdv.14186PubMedGoogle ScholarCrossref
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