Lichen planus and other cutaneous manifestations in chronic hepatitis C: pre- and post-interferon-based treatment prevalence vary in a cohort of patients from low hepatitis C virus endemic area

Bidirectional Association between Lichen Planus and Hepatitis C-An Update Systematic Review and Meta-Analysis

Lichen planus (LP) is a chronic, inflammatory mucocutaneous disorder associated with systemic diseases such as hepatitis C (HCV). The objective of this study is to evaluate the association between LP and HCV bidirectionally through a systematic review and meta-analysis. A comprehensive search of studies published was performed in the databases of PubMed, Embase, and Web of Science. Out of 18,491 articles, 192 studies were included. The global prevalence of HCV positive (HCV+) in LP patients registered from 143 studies was 9.42% [95% confidence interval (CI), 7.27-11.58%], and from these, 84 studies showed HCV+ 4-fold more frequent in LP than a control group (OR, 4.48; 95% CI, 3.48-5.77). The global prevalence of LP in patients HCV+ recorded from 49 studies was 7.05% (95% CI, 4.85-9.26%), and from these, 15 registered a 3-fold more LP in HCV (OR, 3.65; 95% CI, 2.14-6.24). HCV+ in LP patients showed great geographic variability (OR, 2.7 to 8.57), and the predominantly cutaneous location was higher (OR, 5.95) than the oral location (OR, 3.49). LP in HCV+ patients was more frequent in the Eastern Mediterranean (OR, 5.51; 95% CI, 1.40-15.57). There is a higher prevalence of HCV+ in LP and vice versa than in the control group, especially in certain geographical areas that should be taken into consideration when doing screening in countries with an upper prevalence of HCV among the general population.

MRGPRX4 in Cholestatic Pruritus

Pruritus (itch) is a debilitating symptom in liver diseases with cholestasis, which severely affects patients' quality of life. Limited treatment options are available for cholestatic itch, largely due to the incomplete understanding of the underlying molecular mechanisms. Several factors have been proposed as pruritogens for cholestatic itch, such as bile acids, bilirubin, lysophosphatidic acid, and endogenous opioids. Recently, two research groups independently identified Mas-related G protein-coupled receptor X4 (MRGPRX4) as a receptor for bile acids and bilirubin and demonstrated its likely role in cholestatic itch. This discovery not only opens new avenues for understanding the molecular mechanisms in cholestatic itch but provides a promising target for developing novel anti-itch treatments. In this review, we summarize the current theories and knowledge of cholestatic itch, emphasizing MRGPRX4 as a bile acid and bilirubin receptor mediating cholestatic itch in humans. We also discuss some future perspectives in cholestatic itch research.

Comorbidity of viral hepatitis and chronic spontaneous urticaria: A systematic review

Chronic viral infections including those by hepatitis B (CHB) virus and hepatitis C (CHC) virus have been reported to be comorbidities of chronic spontaneous urticaria (CSU). Here, we performed the first comprehensive review of the peer-reviewed literature (PubMed, Web of Science and Google Scholar) on the prevalence of CHB and CHC in patients with CSU and vice versa. The prevalence of CHB and CHC in CSU does not appear to be increased. Less than 5% and 2% of patients with CSU have markers of CHB and CHC, respectively, according to most of the 32 studies reviewed. Urticarial rash including CSU occurs in ≤3% of patients with CHC as reported by most of 20 studies analysed. Very few patients have been assessed for the effects of antiviral hepatitis treatment on their CSU, and two but not all reportedly showed improvement. Hepatitis B/C infections appear unlikely to be linked to CSU. We suggest that routine screening for these infections in patients with CSU is not relevant or cost-effective and should not be performed unless liver function tests are abnormal, risk factors or symptoms of viral hepatitis are present, or urticarial vasculitis is suspected.

Evaluation of the Relationship between Alopecia Areata and Viral Antigen Exposure

BACKGROUND

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring alopecia with T-cell infiltration at the affected hair follicle.

OBJECTIVE

Our aim was to study the potential link between hepatitis B virus (HBV) antigen exposure and AA.

METHODS

Two pediatric patients with AA following hepatitis B vaccination were identified in a general dermatology clinic. A bioinformatics analysis and an electronic medical record (EMR) database query were performed at the University of Rochester Medical Center to identify patients with AA, coexisting viral infections, vaccinations, or interferon (IFN) therapy in order to determine if the presence of AA and these conditions was higher than in AA patients without these associated conditions or therapy.

RESULTS

An increased frequency of AA among those who received the HBV surface protein antigen [odds ratio (OR) 2.7, p < 0.0001] was identified, and an independent analysis revealed an increased frequency of AA in those receiving IFN-β treatment (OR 8.1, p < 0.05). One potential antigenic target identified was SLC45A2, a melanosomal transport protein important in skin and hair pigmentation. The longest potential vaccine peptide fragment match (8-mer) was to a segment of natural killer (NK) cell inhibitory receptors, KIR3DL2 and KIR3DL1. Predictive modeling of major histocompatibility complex (MHC)-peptide binding demonstrated potential binding of this peptide to MHC relevant to AA.

LIMITATIONS

The results will need to be verified in additional patient databases allowing analysis of temporal relationships, and with molecular experiments of the identified antigens.

CONCLUSIONS

Our data confirm associations between viral infection and IFN treatment with AA. It establishes that the hepatitis B surface protein antigen has shared epitopes with human killer immunoglobulin-like receptors.

Increased infiltration of CD11 c+/CD123+ dendritic cell subsets and upregulation of TLR/IFN-α signaling participate in pathogenesis of oral lichen planus

OBJECTIVE

Investigation of dendritic cell (DC) subsets and expression patterns of Toll-like receptors (TLRs) was conducted to understand the pathogenesis in oral lichen planus (OLP).

STUDY DESIGN

Blood, OLP lesion, and control samples were collected. Four DC subsets (CD11c⁺CD123^-myeloid DC1 [mDC1], CD141⁺mDC2, CD11c^-CD123⁺plasmacytoid DC [pDC], and CD1a⁺CD207⁺Langerhans cells [LC]) were investigated via flow cytometry (FCM) and immunohistochemical staining. Expression patterns of TLRs and their downstream molecules were analyzed via quantitative real-time polymerase chain reaction and immunohistochemistry in situ.

RESULTS

Thirty-two samples were collected (9 controls and 23 OLP patients). FCM results found that the percentages of LC, mDC1, mDC2, and pDC in situ were 0.0119 ± 0.0251%, 0.0064 ± 0.0134%, 0.0005 ± 0.0011%, and 0.0022 ± 0.0019% in control mucosa, respectively. The mDC1 (0.0300 ± 0.0276%) and pDC (0.0204 ± 0.0186%) subsets were significantly increased in OLP lesions (P < .01). No marked differences were evident, when comparing all 4 DC subsets from blood, between control and OLP groups. Significant upregulation of TLR7, TLR8, and TLR9 were disclosed in OLP (P < .01), along with their downstream interferon-α (IFN-α) signaling molecules (IRF7 and IFN-α, P < .01).

CONCLUSION

Our findings of increased infiltration of pDC and mDC1, along with upregulation of TLR/IFN-α signaling, provide valuable information for further understanding the immunity in OLP.

Sarcoidosis and chronic hepatitis C: treatment with prednisone and colchicine

Sarcoidosis is a disease which still has uncertain etiology. Possible environmental causes are cited in the literature, like organic and inorganic particles and infectious agents. Recent studies have demonstrated the occurrence of sarcoidosis in patients with chronic C hepatitis; however, this association remains without statistical or causal evidence. In this report a case of sarcoidosis associated with chronic hepatitis C will be described, with subcutaneous lesions, considered rare, and good response to treatment with colchicine and prednisone. The hepatitis C virus was isolated in sarcoid tissue and the association between the two diseases will be discussed.

Cryoglobulinaemia in Egyptian Patients with Extrahepatic Cutaneous Manifestations of Chronic Hepatitis C Virus Infection

Background. Hepatitis C is a global major health problem with extremely variable extrahepatic manifestations. Mixed cryoglobulinaemia (MC) shows a striking association with hepatitis C virus (HCV) infection, and it is sometimes asymptomatic. The skin is a frequently involved target organ in MC. Objective. To investigate the prevalence of cryoglobulinaemia in a sample of Egyptian patients with cutaneous manifestations of chronic HCV infection and to correlate its presence with clinical criteria and liver function tests. Methods. One hundred and eighteen patients with skin manifestations of chronic compensated hepatitis C were included. Venous blood was tested for liver function tests and serum cryoglobulins. Results. Twelve patients (10.169%) were positive for serum cryoglobulins (2 with pruritus, 4 with vasculitic lesions, 3 with livedo reticularis, one with oral lichen, one with chronic urticaria, and another with Schamberg's disease). Vasculitic lesions and livedo reticularis of the legs showed higher prevalence in cryoglobulin-positive than in cryoglobulin-negative patients. Presence of serum cryoglobulins did not relate to patients' demographic or laboratory findings. Conclusions. Fortunately, MC is not markedly prevalent among Egyptians with cutaneous lesions of chronic hepatitis C, and cryopositivity was commonly, but not exclusively, detected with cutaneous vasculitis and livedo reticularis. Laboratory testing for cryoglobulins in every HCV patient is advisable for earlier MC detection and management.

Pruritus epidemiology and quality of life

The burden of chronic pruritus is increasingly recognized as significant worldwide. As wet-laboratory researchers investigate the pathophysiology of chronic pruritus, epidemiologists and health services researchers are quantifying the impact of pruritus by incidence, prevalence, and quality of life measures. Outcomes researchers are also investigating factors that may predict chronic pruritus incidence and severity. Such efforts will direct resources for research, public health intervention, and clinical care.

Pruritus in Systemic Diseases: A Review of Etiological Factors and New Treatment Modalities

Pruritus is the most frequently described symptom in dermatology and can significantly impair the patient's quality of life. In 10–50% of adults with persistent pruritus, it can be an important dermatologic clue for the presence of a significant underlying systemic disease such as renal insufficiency, cholestasis, hematologic disorder, or malignancy (Etter and Myers, 2002; Zirwas and Seraly, 2001). This review describes the presence of pruritus in different systemic diseases. It is quite important to discover the cause of pruritus for providing relief for the patients experiencing substantial morbidity caused by this condition.

Impact of added fluvastatin to standard-of-care treatment on sustained virological response in naïve chronic hepatitis C Patients infected with genotypes 1 and 3

OBJECTIVES

The combination of pegylated interferon-α and ribavirin is a standard-of-care (SOC) treatment for chronic hepatitis C (CHC), and it achieves a sustained virological response (SVR) in 41-52% of genotype 1 and in 73-79% of genotype 3 patients. In a few clinical trials, the combination of fluvastatin and SOC increased the SVR in genotype 1 patients.

METHODS

This prospective study enrolled 179 naïve CHC patients. In the fluvastatin group patients received the combination of SOC and fluvastatin 80 mg daily; historical controls matching the study group in genotype, age and gender were treated with the SOC treatment only.

RESULTS

On-treatment viral responses as well as the SVR did not differ significantly between the two groups, except for the genotype 1 patients with a high viral load presenting a significantly higher SVR rate in the fluvastatin group (75%) compared to the control group (41%; p = 0.024). Multivariate logistic regression identified hepatitis C virus (HCV) genotype 3 infection (p < 0.001), age ≤40 years (p < 0.001), liver steatosis <5% (p < 0.01) and low viral load (p < 0.001) as independent predictors of an SVR.

CONCLUSION

A combination of fluvastatin and SOC significantly improved the SVR in naïve CHC patients infected with HCV genotype 1 and high viral load, but it did not improve the SVR in patients infected with HCV genotype 3.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Cholestatic pruritus: a retrospective analysis on clinical characteristics and treatment response

BACKGROUND

Chronic cholestatic pruritus (ChP) is caused by various hepatobiliary disorders. This retrospective study describes the distribution of underlying diseases, clinical characteristics and treatment efficacy in a consecutive collective of patients with ChP.

PATIENTS AND METHODS

Extensive data from 60 patients with ChP (30 women, 30 men; mean age: 58.0 ± 17.0 years) were retrospectively statistically analyzed concerning demographic data, pruritus characteristics, and response to therapy.

RESULTS

In this study population, 40.0% of the patients suffered from hepatitis B or C. Regarding the overall population, pruritus started in 50% of patients after diagnosis of the underlying hepatobiliary disorder. Only in patients with immune-mediated liver diseases did pruritus more often occur before diagnosis (p < 0.05). Only 23.3% of the patients reported an initial palmoplantar pruritus. Along with other drugs, anticonvulsants proved to be an effective treatment regime.

CONCLUSIONS

In this study, viral pathogenesis was the most common cause of ChP. Other underlying diseases were represented to a lower extent in the total study population. Overall, the collected clinical parameters in each group were comparable. Thus, it was difficult to draw conclusions on the pathogenesis.

Different patterns of dermatological presentations in patients co-infected with human immunodeficiency virus and hepatitis C virus (HCV), and those infected with HCV alone

BACKGROUND

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share the same transmission routes. About 30% of HIV-positive patients are co-infected with HCV. Of the various HCV-related extrahepatic events, those involving the skin may be the first sign of infection.

AIM

To specify the skin presentations in patients co-infected with HIV and HCV (co-infected patients; CP) and compare them with those found in patients with HCV mono-infection (mono-infected patients; MP).

METHODS

This was a cross-sectional study, in which the studied population consisted of MP and CP from a tertiary hospital in the South of Brazil, who underwent complete skin examination and laboratory tests.

RESULTS

In total, 201 patients were assessed, of whom 108 were CP, and 93 were MP. Pruritus tended to be more common in MP. MP also had significantly more dermatological conditions (mean of 5.2) than CP (mean of 4.5). In total, 104 different skin diseases were identified. There was a higher prevalence of infectious diseases and pigmentation disorders, such as verruca vulgaris and facial melasma, in CP, whereas trunk and facial telangiectasias, palmar erythema, and varicose veins were more common in MP.

CONCLUSION

We found a high prevalence of skin conditions both in MP and in CP; however, the patterns of the dermatological conditions were different. CP were found to have significantly fewer skin lesions than MP, but had a higher prevalence of infectious and pigmentation disorders. By contrast, vascular conditions were more common in MP.

[Interferon-alpha and hepatitis C virus: the skin matters]

Chronic hepatitis C virus infection (HCV) is classically associated with such dermatologic conditions as mixed cryoglobulinemia (MC), porphyria cutanea tarda (PCT) and lichen planus. This review focuses on the response of these entities to interferon alpha (IFN) therapy, which has an immunomodulatory activity and may modify their course. The presence of certain HCV-associated dermatologic disorders, as PCT, may predict the patients virological response to IFN therapy. On the other hand, the course of some dermatologic disorders, as MC, during treatment with IFN, may be an early indicator of virologic response. In any case, physicians should know how to handle the most common dermatologic side effects of IFN, which may affect the quality of life of patients, complicating the adherence to treatment.

A study on the association with hepatitis B and hepatitis C in 1557 patients with lichen planus

BACKGROUND

Previous reports have demonstrated contradicting results on the association between lichen planus and hepatitis.

OBJECTIVES

The aim of this study was to investigate the association between lichen planus and viral hepatitis.

METHODS

Patients with lichen planus were compared with controls regarding the prevalence of viral hepatitis in a case-control study using logistic multivariate regression models. The study was performed utilizing the medical database of Clalit Health Services.

RESULTS

The study included 1557 lichen planus patients over the age of 20 years and 3115 age- and gender-matched controls. The prevalence of hepatitis C in patients with lichen planus was higher than that in the control group (1.9%, 0.4% respectively, P<0.001). In a multivariate analysis, lichen planus was associated with hepatitis C (OR 4.19, 95% CI 2.21; 7.93). The prevalence of hepatitis B in patients with lichen planus was similar to that in the control group (0.9%, 0.5% respectively, P=0.12). A multivariate analysis revealed that lichen planus was not associated with hepatitis B (OR 1.69, 95% CI 0.82; 3.47).

CONCLUSION

Lichen planus is associated with hepatitis C but not with hepatitis B. Physicians who care for patients with lichen planus should consider screening patients with lichen planus for hepatitis C.

Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy

Chronic pruritus is a major and distressing symptom of many cutaneous and systemic diseases and can significantly impair the patient's quality of life. Pruritus perception is the final result of a complex network involving dedicated nerve pathways and brain areas, and an increasing number of peripheral and central mediators are thought to be involved. Itch is associated with most cutaneous disorders and, in these circumstances, its management overlaps with that of the skin disease. Itch can also occur without associated skin diseases or primary skin lesions, but only with nonspecific lesions secondary to rubbing or scratching. Chronic itch with no or minimal skin changes can be secondary to important diseases, such as neurologic disorders, chronic renal failure, cholestasis, systemic infections, malignancies, and endocrine disorders, and may also result from exposure to some drugs. The search for the cause of pruritus usually requires a meticulous step-by-step assessment involving careful history taking as well as clinical examination and laboratory investigations. Few evidence-based treatments for pruritus are available. Topical therapy, oral histamine H(1) receptor antagonists, and phototherapy with UV radiation can target pruritus elicitation in the skin, whereas antiepileptic drugs, opioid receptor antagonists, and antidepressants can block signal processing in the CNS.