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Skin findings may lead to detection
of hepatitis C

The hepatitis C virus (HCV), which was first detected in 1989, is spread by direct contact with infected blood of body fluids. It affects approximately two per cent of the population. Risk factors include intravenous drug use, intranasal cocaine use, tattoos and body piercing with non-sterile equipment, blood transfusions (especially prior to 1990), long-term hemodialysis and organ transplantation.

The risk of acquiring the infection after transfusion from an anti-HCV antibody-positive donor is greater than 80 per cent. HCV infection is frequently asymptomatic and liver enzymes may be normal. Approximately 70 per cent develop chronic hepatitis. This is a significant infection since cirrhosis develops in one-half to one-third of people with chronic hepatitis, and hepatocellular carcinoma in four per cent. The risk of cirrhosis is increased with excessive alcohol consumption and concurrent hepatitis B infection. There are different strains or genotypes of this RNA virus. Some genotypes, such as 1b, are associated with chronicity and progression.

Many extrahepatic diseases have been associated with HCV infection. Cutaneous manifestations are common and may be the first suggestion of infection. They are discussed on pages 1 and 23. Pruritus and xerostomia are common, although xerophthalmia and anti-Ro antibodies are not features. Cry globulin-associated vasculitis is present in about one-quarter of patients. Conversely, approximately 80 per cent of mixed cryoglobulinemia is related to hepatitis C infection. Clinical manifestations include palpable purpura, arthralgias and weakness; other organs such as the brain and kidney can also be affected. Antiviral therapy usually results in clinical improvement. Porphyria cutanea tarda is associated with HCV in 10 to 90 per cent of cases. Some studies have also shown an association with lichen planus and polyarteritis nodosa.

In conclusion, skin disease may be the initial presentation of HCV infection. Patients with mixed cryoglobulinemia, porphyria cutanea tarda, and those at higher risk for HCV who have any of the other disorders discussed above, should be tested for anti-HCV antibodies. Liver function testing is not sufficient since liver enzymes may be normal.