eISSN: 2299-0046
ISSN: 1642-395X
Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii
Current issue Archive Manuscripts accepted About the journal Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors
SCImago Journal & Country Rank
2/2022
vol. 39
 
Share:
Share:
more
 
 
Letter to the Editor

Severe chronic atopic dermatitis improvement after hepatitis C virus elimination with sofosbuvir/ledipasvir treatment

Anna Szymanek-Pasternak
1, 2
,
Justyna Janocha-Litwin
1, 2
,
Krzysztof Simon
1, 2

1.
Department of Infectious Diseases and Hepatology, Wroclaw Medical University, Wroclaw, Poland
2.
1st Department of Infectious Diseases, Regional Specialist Hospital, Wroclaw, Poland
Adv Dermatol Allergol 2022; XXXIX (2): 424-425
Online publish date: 2022/05/09
Article file
- Severe chronic.pdf  [0.07 MB]
Get citation
ENW
EndNote
BIB
JabRef, Mendeley
RIS
Papers, Reference Manager, RefWorks, Zotero
AMA
APA
Chicago
Harvard
MLA
Vancouver
 
 

Chronic hepatitis C virus (HCV) infection is known to be associated not only with chronic hepatitis (CHC) but also with a wide range of extrahepatic manifestations (EHMs). EHMs can be divided into those of a high degree of association with HCV and those with probable or possible association. The first group includes mixed cryoglobulinemic syndrome and B-cell non-Hodgkin’s lymphoma. EHMs that are probably associated with HCV include diabetes mellitus type 2 (T2DM), membrane proliferative glomerulonephritis, neurological impairment, health related quality of life (HRQoL), sicca syndrome, porphyria cutanea tarda and lichen planus while presence of autoantibodies, cardiovascular events and Mooren’s corneal ulcer are possibly associated with HCV infection [1]. Some of these manifestations resolve or significantly improve after HCV elimination which was shown by multiple studies [1, 2].

In this paper we present a case study of a patient who eliminated HCV after treatment with directly acting antiviral agents (DAA), which subsequently resulted not only in marked improvement of T2DM and HRQoL but also in significant improvement of severe atopic dermatitis (AD) – a condition that up to now has not been known to be associated with HCV infection.

We present the case of a 59-year-old man who has been suffering from severe chronic atopic dermatitis since early childhood and who in the past was treated with several standard therapeutic regimens (psoralen plus ultraviolet A therapy, systemic corticosteroids, H1-blocking antihistamines, azathioprine, cyclosporine A, topical corticosteroids: fluocinolone, flumetasone, encortolon and other topical agents: clioquinol, bituminosulfonate) without any satisfactory and lasting results. Treatment with cyclosporine was complicated with acute kidney injury (AKI) and arterial hypertension (HTA). AKI resolved after cyclosporine discontinuation but HTA still requires hypotensive treatment. From the age of 7 to 25 he was treated with systemic glucocorticosteroids, which was complicated with recurrent bacterial skin infections and finally with sepsis followed by the bacterial coxarthritis that resulted in the destruction of the hip joint requiring alloplasty. In addition, since the age of 2, the patient has been suffering from severe bronchial asthma and has been hospitalized multiple times for exacerbations of the disease and asthmatic conditions. The patient also suffers from peripheral polyneuropathy, neurogenic bladder, urolithiasis of both kidneys and bladder. He also had 6 episodes of iritis of the left eye.

In 2016, the patient was diagnosed with HCV infection, genotype 1b and occult HBV infection (anti-HBc antibodies positive, HBs antigen negative, serum HBV DNA negative). Transient elastography showed moderate liver fibrosis (10.2 kPa). The same year he was diagnosed with T2DM. In 2017, he started 12-week treatment with sofosbuvir/ledipasvir (SOF/LED) for HCV infection. At the moment of anti-HCV treatment initiation the severity of AD – as assessed with the Scoring Atopic Dermatitis (SCORAD) – was 68.4 and health related quality of life (HRQoL) assessed with Sort Form 36 (SF-36) was 139. The patient was receiving the following treatment for his comorbidities: topical clobetasol and methylprednisolone 4 mg daily for AD, fluticasone and salmeterol inhalations twice daily, theophylline 250 mg once daily, fenoterol inhalation if necessary, cetirizine 5 mg once daily for asthma, premixed insulin lispro protamine suspension 50/50 8 IU twice daily and gliclazide modified release 30 mg once daily for diabetes, hydrochlorothiazide 25 mg once daily, diltiazem 120 mg once daily and valsartan 160 mg once daily for HTA, amitriptyline 25 mg twice daily for neuropathy. At the end of SOF/LED treatment (ETR) and 12 weeks after treatment (SVR), serum HCV RNA was negative. During and after SOF/LED treatment AD and HRQoL have been improving significantly. Nine months after SOF/LED termination, SCORAD was 18.1 (73.5% reduction) and SF-36 – 61 (56% improvement). Treatment with methylprednisolone for AD was discontinued and the patient required only minor doses of topical clobetasol. The patient has also been reporting less fatigue and significant improvement in fresh memory and spatial orientation. Due to repeated episodes of hypoglycaemia during SOF/LED treatment, the dose of insulin was reduced to 8 IU daily and gliclazide was discontinued. This treatment for T2DM was maintained after SOF/LED termination. On the other hand, there was no improvement of polyneuropathy or HTA was observed after achieving SVR.

Many skin disorders have been associated with CHC, some with better established causality than others. These disorders include purpura, porphyria cutanea tarda, lichen planus, necrolytic acral erythema, erythema multiforme, and pruritus. Less commonly reported skin manifestations include psoriasis and cutaneous form of sarcoidosis [3]. AD has not yet been observed as one of the HCV-EHMs. To date, no significant improvement in AD has been reported after elimination of HCV infection. It is difficult to explain unequivocally the possible basis of our observation, however, first of all immunological mechanisms should be taken into account. AD is a T cell-mediated inflammatory disease, mainly with an aberrant Th2-type cytokine production [4]. Th1 and Th2 cytokine response has been confirmed to be correlated with the pathogenesis of HCV infection and Th2 biased cytokine responses seem implicated in HCV pathogenesis and severity of liver disease [5] as well as may contribute to HCV-related hepatocellular carcinoma progression and pathogenesis [6]. Therefore, improved Th1/Th2 balance after HCV elimination might have also influenced AD course.

HCV is known to be associated with various neuropsychiatric disorders. This includes depression whose prevalence is higher in CHC patients than in general population [7], fatigue (prevalence 53%) [8] and cognitive impairment [9]. Mood and neurological disorders in turn negatively affect HRQoL [2]. Multiple studies have shown marked improvement of neuropsychiatric EHMs namely: depression [10], neurocognitive performance [11], as well as HRQoL [12, 13]. It has been proven that patients with HCV have worse results than controls across all scales of the SF-36. On the other hand, achieving SVR positively influences all SF-36 scales comparing to non-achieving SVR, especially in the physical health domains. HRQoL differences did not correspond with differences in liver histology or ALT levels [14]. In our patient better results in SF-36 after SVR may result not solely from HCV elimination but also from significant AD improvement.

In conclusion, to the best of our knowledge, this is the first case report of AD improvement after elimination of HCV upon DAA treatment.

Acknowledgments

The work was conducted and should be attributed to the Department of Infectious Diseases and Hepatology, Wroclaw Medical University, Poland and 1st Department of Infectious Diseases, Regional Specialist Hospital in Wroclaw, Poland.

Conflict of interest

The authors declare no conflict of interest.

References

1 

Tang L, Marcell L, Kottilil S. Systemic manifestations of hepatitis C infection. Infect Agent Cancer 2016; 11: 29.

2 

Zignego AL, Ramos-Casals M, Ferri C, et al. International therapeutic guidelines for patients with HCV-related extrahepatic disorders. A multidisciplinary expert statement. Autoimmun Rev 2017; 16: 523-41.

3 

Gill K, Ghazinian H, Manch R, Gish R. Hepatitis C virus as a systemic disease: reaching beyond the liver. Hepatol Int 2016; 10: 415-23.

4 

Nomura T, Honda T, Kabashima K. Multipolarity of cytokine axes in the pathogenesis of atopic dermatitis in terms of age, race, species, disease stage and biomarkers. Int Immunol 2018; 30: 419-28.

5 

Gramenzi A, Andreone P, Loggi E, et al. Cytokine profile of peripheral blood mononuclear cells from patients with different outcomes of hepatitis C virus infection. J Viral Hepat 2005; 12: 525-30.

6 

Yue M, Deng X, Zhai X, et al. Th1 and Th2 cytokine profiles induced by hepatitis C virus F protein in peripheral blood mononuclear cells from chronic hepatitis C patients. Immunol Lett 2013; 152: 89-95.

7 

Ashrafi M, Modabbernia A, Dalir M, et al. Predictors of mental and physical health in non-cirrhotic patients with viral hepatitis: a case control study. J Psychosom Res 2012; 73: 218-24.

8 

Poynard T, Cacoub P, Ratziu V, et al. Fatigue in patients with chronic hepatitis C. J Viral Hepat 2002; 9: 295-303.

9 

Solinas A, Piras MR, Deplano A. Cognitive dysfunction and hepatitis C virus infection. World J Hepatol 2015; 7: 922-5.

10 

Boscarino JA, Lu M, Moorman AC, et al. Predictors of poor mental and physical health status among patients with chronic hepatitis C infection: The Chronic Hepatitis Cohort Study (CHeCS). Hepatology 2015; 61: 802-11.

11 

Kraus MR, Schäfer A, Teuber G, et al. Improvement of neurocognitive function in responders to an antiviral therapy for chronic hepatitis C. Hepatology 2013; 58: 497-504.

12 

Isaacs D, Abdelaziz N, Keller M, et al. Measuring the response of extrahepatic symptoms and quality of life to antiviral treatment in patients with hepatitis C. Hepat Res Treat 2013; 2013: 910519.

13 

John-Baptiste AA, Tomlinson G, Hsu PC, et al. Sustained responders have better quality of life and productivity compared with treatment failures long after antiviral therapy for hepatitis C. Am J Gastroenterol 2009; 104: 2439-48.

14 

Spiegel BMR, Younossi ZM, Hays RD, et al. Impact of hepatitis C on health related quality of life: a systematic review and quantitative assessment. Hepatology 2005; 41: 790-800.

Copyright: © 2022 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
Quick links
© 2022 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.