• primarily associated with hepatitis C virus (HCV) infection. It was first described in 1996 and has been reported in various regions, especially in Egypt, where it is more commonly found in patients with chronic HCV infection.
• The condition typically presents with red, scaly, and often itchy plaques on the skin, particularly affecting the acral areas extremities such as hands, feet, and ankles.

• Necrolytic Acral Erythema (NAE) is a rare condition. It has been reported in both males and females and across different age groups.
• NAE was first described in Egypt and has been most reported in Egyptian patients with chronic HCV infection. It has also been observed in other parts of the Middle East, including Saudi Arabia and Iran. Cases have also been reported in other regions, but they are relatively less frequent.
• NAE has a strong association with chronic HCV infection. Most patients with NAE have concurrent HCV infection, but not all HCV-infected individuals develop NAE.

• NAE is strongly connected to chronic HCV infection. The virus may directly or indirectly influence the skin’s immune response, leading to the characteristic skin lesions.
• Glucagon, a hormone produced by the pancreas and plays a role in the pathogenesis of NAE. In individuals with HCV-related liver disease, there may be an alteration in glucagon metabolism.
• Zinc is an essential trace element required for numerous biological processes, including skin health and wound healing. In some cases of NAE, there is evidence of zinc deficiency, which may play a significant role in the development of skin lesions.

• NAE is commonly seen in individuals with chronic liver disease, particularly those with advanced liver cirrhosis. Liver dysfunction and its complications may contribute to the development of NAE.
• Alterations in the immune response and inflammation have been observed in the affected skin areas of individuals with NAE.
• In patients with HCV-associated liver disease, there may be abnormalities in glucagon metabolism. Zinc is an essential trace element with crucial roles in various physiological processes, including skin health and wound healing.

• As there is limited information available on prognosis. NAE is seen in patients with advanced liver disease and cirrhosis. The severity of liver dysfunction may have an impact on the progression and response to treatment of NAE.
• The age of onset of NAE and the duration of skin lesions may provide some insights into the disease’s progression and potential response to treatment.

Age Group:

• Necrolytic Acral Erythema can occur in individuals of various age groups, but it is more commonly reported in middle-aged and older individuals.
• The typical age range for NAE is between 40 and 70 years old, with most cases occurring in individuals in their 50s and 60s.

Skin Lesions: The dermatologist will inspect the skin, paying close attention to the extremities such as hands, feet, and ankles. They will look for red, scaly, and sometimes blistering plaques with well-defined borders. The lesions may be irregularly shaped and tend to be symmetrical in distribution.

• NAE typically affects multiple acral sites, but it can vary from person to person. The patient may report itching and discomfort associated with the skin lesions.
• In severe cases or when NAE has been present for a prolonged period, there may be evidence of skin breakdown, ulceration, and crusting.

• The most significant association with NAE is chronic Hepatitis C Virus (HCV) infection. NAE is often seen in individuals with HCV-related liver disease.
• NAE is frequently observed in patients with advanced liver disease, particularly those with liver cirrhosis. The severity of liver dysfunction may influence the development and progression of NAE in some cases.
• Some cases of NAE have been associated with zinc deficiency. Zinc is an essential trace element required for various physiological processes, including skin health.

• NAE often starts with mild and nonspecific symptoms, such as redness and itching in the affected skin areas. These initial symptoms may not cause significant concern or prompt immediate medical attention.
• Over time, the skin symptoms tend to worsen and progress. The red, scaly, and sometimes blistering plaques on the acral areas (hands, feet, ankles) may become more pronounced and widespread.
• NAE is considered a chronic condition, meaning that it persists over an extended period rather than resolving quickly. It can last for weeks, months, or even years.

• Hepatitis C Infection: Since NAE is strongly associated with chronic hepatitis C virus (HCV) infection, managing the underlying viral infection is essential. Antiviral medications, such as direct-acting antivirals (DAAs), are the mainstay of HCV treatment and have shown efficacy in clearing the virus in many cases. Successful HCV treatment may lead to improvement or resolution of NAE lesions.
• Zinc deficiency: In some cases of NAE, zinc deficiency has been implicated as a contributing factor. Zinc supplementation may be beneficial in these cases.
• Emollients and Moisturizers: Using emollients and moisturizers can help soothe and hydrate the affected skin, promoting comfort and potentially aiding in healing.
• Immunosuppressive Therapy: In certain cases of NAE that are unresponsive to other treatments, immunosuppressive medications may be considered.

Dermatology, General

• Avoiding Irritants: Identify and avoid any potential irritants that may exacerbate the skin condition. This may include certain skincare products, detergents, or other chemicals that could worsen skin irritation.
• Protection of Skin: Protect the affected skin from friction, trauma, and excessive sun exposure. Wearing loose-fitting clothing made from soft fabrics can help prevent additional irritation.
• Proper Hydration: Keeping the skin well-hydrated is essential. Regularly using emollients and moisturizers can soothe dry and inflamed skin, reducing itching and discomfort.
• Comfortable Environment: Maintaining a cool and comfortable environment can help minimize sweating and prevent overheating of the skin.
• Good Hygienic Practices: Practicing good hygiene can prevent infection and promote wound healing. Regularly clean and dress any open or ulcerated NAE lesions as advised by healthcare professionals.

Dermatology, General

In cases where zinc deficiency is identified as a contributing factor to NAE, zinc supplementation may be prescribed to address the deficiency. Adequate zinc levels are important for skin health and wound healing.

• Zinc: It is an essential trace element that plays a crucial role in various physiological processes, including wound healing, immune function, and maintaining skin integrity. It is involved in the synthesis of proteins and enzymes, and it also has anti-inflammatory properties.

Dermatology, General

Interferons are a group of proteins that are part of the body’s immune response against viral infections and other pathogens. They have been used in the treatment of various medical conditions, including viral hepatitis and certain cancers.

• Peginterferon alfa-2a: It is employed in combination with ribavirin to manage individuals with chronic hepatitis C who possess compensated liver ailment and have not formerly undergone interferon alfa. It is composed of interferon alfa-2a connected to a 40-kd branched PEG compound. Peginterferon alfa-2a is mainly processed by the liver.

• Peginterferon alfa-2b: It is a recombinant product derived from Escherichia coli. It is prescribed for individuals with compensated liver disease who have not received previous treatment with interferon alfa, to address chronic hepatitis C. The mechanism of action of Peginterferon alfa-2b involves binding to specific receptors on the surface of cells, potentially inhibiting cell growth and boosting the phagocytic activity of macrophages.

Dermatology, General

Nucleoside analogs are a class of antiviral medications commonly used to treat viral infections, such as hepatitis B and HIV. They work by interfering with viral replication, ultimately reducing the viral load in the body. Nucleoside analogs are drugs that interfere with the production of DNA and RNA.

• Ribavirin: It is an antiviral nucleoside analogue. Administered alone, ribavirin has minimal impact on the progression of hepatitis C. When administered alongside interferon, it greatly enhances the rate of sustained virologic response.

Dermatology, General

• Wound Debridement: Debridement involves the removal of necrotic (dead) tissue from the ulcerated skin lesions. This can help clean the wounds, promote granulation tissue formation, and enhance the healing process.
• Topical Dressings: In some cases, specialized dressings may be applied to the affected skin areas to protect the wounds, maintain a moist wound environment, and prevent infection. These dressings can be tailored to the specific needs of the patient.
• Biopsy for Diagnosis: A skin biopsy may be performed to confirm the diagnosis of NAE and rule out other skin conditions with similar presentations. This can be particularly important when the diagnosis is uncertain or when atypical features are present.

Dermatology, General

• Initial Diagnosis Phase: The first phase involves a thorough medical history, physical examination, and appropriate tests to establish the diagnosis of NAE and determine any underlying factors, such as hepatitis C virus (HCV) infection or zinc deficiency.
• Treatment Phase: If an underlying cause is identified, such as chronic HCV infection or zinc deficiency, appropriate treatment is initiated. Zinc supplementation may be prescribed in cases of zinc deficiency.
• Relief Phase: During this phase, treatments are aimed at providing relief from the symptoms of NAE, such as itching and inflammation. Topical treatments, emollients, and moisturizers may be prescribed to soothe the skin and reduce discomfort.
• Monitoring and Follow-up Phase: Regular monitoring and follow-up are essential to assess the patient’s response to treatment, track disease progression, and manage any complications.