Authors: Lavanyah Anbazhagan, MD; Umesh Doppalapudi, MD; Shail Bhatnagar, MD
Department of Family Medicine, Baptist Health North Little Rock — University of Arkansas for Medical Sciences, Arkansas
About this page: This is the accessible text version of the poster above. Clinical photograph descriptions are written in clinical, non-graphic terms; the original patient photographs are not included in the text version.
Introduction
Porphyria cutanea tarda (PCT) is the most common form of porphyria and results from decreased activity of uroporphyrinogen decarboxylase. It is strongly associated with chronic liver disease, particularly chronic hepatitis C virus (HCV) infection. HCV contributes to PCT through mechanisms such as hepatic iron accumulation and oxidative stress, leading to inhibition of enzyme activity (see Figure 1). Recognition of this association is critical, as treatment of HCV can result in remission of PCT.
Purpose
To illustrate a rare condition (PCT) to help clinicians recognize and screen patients with chronic liver disease who present with characteristic skin findings.
Patient Presentation
A 53-year-old male with relevant past medical history of hypertension, chronic hepatitis C, and substance use disorder (alcohol abuse and fentanyl) was brought in by EMS for suspected seizure activity.
On admission, he endorsed bilateral arm and leg swelling with erythema and pain. This led to initial suspicion for cellulitis. Further discussion and evaluation of the patient revealed that the affected areas were photosensitive blistering lesions on sun-exposed areas, most notably on the dorsal hands (see Image A).
Physical examination revealed skin fragility with crusted erosions and atrophic scars on the dorsal hands and forearms, and on both quadriceps and feet (see Images B and C).
Clinical Image Descriptions
Image A — Dorsal hands. Close-up clinical photograph of the dorsal (back) surfaces of both hands. The skin shows multiple discrete erosions and post-inflammatory hyperpigmented patches, consistent with a photosensitive blistering process. Several lesions appear to be in different stages of healing.
Image not displayed in the accessible text version. Please refer to the original poster for the clinical photograph.Image B — Forearm / lower extremity. Clinical photograph showing skin fragility with crusted erosions and atrophic scarring on an extremity. The pattern is consistent with chronic photosensitive injury described in the case.
Image not displayed in the accessible text version.Image C — Feet / lower extremity. Clinical photograph of the lower extremity showing similar atrophic scars and crusted erosions on sun-exposed skin, supporting the diagnosis of a chronic photosensitive disorder.
Image not displayed in the accessible text version.
Figure 1: HCV and PCT Pathway
Figure 1. A vertical pathway diagram illustrating how chronic Hepatitis C infection leads to porphyria cutanea tarda. The diagram flows from top to bottom in four labeled stages with arrows connecting each:
- Hepatitis C Virus (HCV) — chronic viral infection.
- Iron Overload — HCV contributes to hepatic iron accumulation.
- Oxidative Stress — iron accumulation produces oxidative stress in hepatocytes.
- Porphyria Cutanea Tarda (PCT) — oxidative stress inhibits uroporphyrinogen decarboxylase, producing the characteristic skin findings.
Clinical Course
Laboratory findings consistent with the suspected diagnosis of porphyria cutanea tarda are summarized below.
| Test | Result |
|---|---|
| Hepatitis C antibody | 7.44 S/CO (elevated) |
| Ferritin | 310.4 ng/mL |
| Uroporphyrin plasma level | 0.6 mcg/L |
The patient was also worked up for other conditions, including tick-borne illness, which resulted negative. Unfortunately, the patient left against medical advice before the 24-hour urine porphyrins could be collected. The plan was to initiate antiviral therapy for hepatitis C on an outpatient basis.
Discussion
PCT is frequently associated with chronic liver disease, including:
- Hepatitis C infection or HIV
- Alcohol use
- Smoking
- Iron overload
In patients with HCV, dermatologic manifestations may precede hepatic symptoms, making early recognition essential.
Management strategies
- Phlebotomy to reduce iron overload.
- Low-dose hydroxychloroquine to mobilize porphyrins.
- Treatment of underlying HCV (typically with direct-acting antivirals such as sofosbuvir–velpatasvir), which has been shown to induce sustained remission.
The pathophysiologic link between HCV and PCT highlights the importance of screening for liver disease in patients presenting with cutaneous findings suggestive of porphyria.
Conclusion
Porphyria cutanea tarda should be considered in patients with chronic hepatitis C who present with photosensitive blistering skin lesions. Early diagnosis and targeted treatment — including management of the underlying HCV infection — can significantly improve clinical outcomes and lead to remission of disease.
References
- Usta Atmaca H, Akbas F. Porphyria cutanea tarda: a case report. Journal of Medical Case Reports. 2019 Jan 21;13(1):17. doi:10.1186/s13256-018-1956-9.
- Callen J. Hepatitis C Viral Infection and Porphyria Cutanea Tarda. The American Journal of the Medical Sciences, 354, 5–6.
- John JJ, Sterling RK. Hepatitis-Induced Porphyria: Are Direct-Acting Antiviral Agents the Way of the Future? ACG Case Reports Journal 8(5):e00581, May 2021.