Hepatitis C Rash: Skin Symptoms and Signs of Progression

Rashes and other skin symptoms are common with hepatitis C, a liver infection caused by the hepatitis C virus (HCV). They can occur in the initial acute infection, as side effects of hepatitis C medications, or as complications from later-stage liver disease, such as cirrhosis (liver scarring) or liver cancer.

Although hepatitis C is usually asymptomatic (without symptoms) until liver damage is advanced, one in six people will develop at least one skin symptom during the course of the infection.

Skin symptoms range from red spots and swelling to chronic itching and changes in skin color. These symptoms are often overlooked or mistaken for other conditions, such as allergies or autoimmune skin disease.

Because skin-related symptoms may be the only signs of hepatitis C, it is important to recognize them so that treatment can be delivered before significant liver damage has occurred.

This article describes the different types of rashes and skin conditions associated with hepatitis C, including their causes and treatment options.

Asymptomatic and Symptomatic Hepatitis C Infection

Hepatitis C progresses in stages. During the initial acute phase, the disease is usually asymptomatic. As many as 30% will spontaneously clear the virus (it is no longer present in their bodies) without knowing they had it. The rest will develop a chronic (persistent) infection, of whom 15% to 30% will develop cirrhosis within 20 years.

As the disease slowly progresses, the likelihood of symptoms will increase. Even so, most people with chronic HCV infection will have either no symptoms or nonspecific signs such as chronic fatigue or depression.

While most people associate hepatitis C with liver-related symptoms, one in four people with a chronic HCV infection will develop extrahepatic symptoms (meaning symptoms outside the liver).

These include skin-related symptoms that can occur during the acute and chronic stages and from hepatitis C treatment.

Rash Symptoms From Acute HCV Infection

Acute hepatitis C symptoms occur in around 20% of people exposed to the virus. The symptoms usually develop two to 12 weeks after exposure and cause symptoms ranging from nausea and vomiting to dark urine and jaundice (yellowing of the skin and/or eyes).

A less common symptom of acute HCV infection is urticaria, a widespread, itchy rash also known as hives. Urticaria is characterized by raised, red welts with well-defined borders.

Rashes Associated With Chronic HCV

Many skin conditions are associated with chronic hepatitis C, some common and others uncommon. They include pruritus (itching), a common condition affecting up to 40% of those with chronic HCV infection.

Four skin conditions directly linked to HCV can cause rashes during the chronic stage of infection:

• Lichen planus: This is an inflammatory condition caused by an abnormal immune response that affects the skin and mucous membranes. Symptoms include flat, purplish, itchy bumps on the skin, swollen gums, and painful erosive patches on the tongue.
• Mixed cryoglobulinemia: This is an inflammatory condition caused by an abnormal immune response that affects blood vessels. Symptoms include a raised, purplish skin rash (called palpable purpura), typically on the lower legs. Itchiness is also common.
• Porphyria cutanea tarda: This is a rare condition that causes painful lesions on sun-exposed areas of skin. Hyperpigmentation (darkening of the skin), hypopigmentation (loss of skin color), and waxy, hardened skin plaques can also occur.
• Necrolytic acral erythema: This is another rare condition that starts with an outbreak of blistering rash that soon evolves into darkened areas of hardened, cracked skin. The feet are most commonly affected.

These skin conditions can occur for reasons other than hepatitis C. Even so, HCV testing is recommended due to their strong association with HCV.

Prurigo nodularis, a chronic itchy skin condition with a symmetrical rash, is also more common in people with hepatitis C.

Rashes From HCV Treatment

Hepatitis C is treated with a class of drugs called direct-acting antiviral (DAAs). While DAAs can cure the vast majority of HCV infections, they can also cause side effects, including fatigue, nausea, diarrhea, and vomiting.

Skin-related side effects can also occur during treatment, after treatment, or both, typically causing:

• Itching
• Rash
• Skin dryness
• Changes in skin color
• Scaling

Skin reactions were more common with older, discontinued DAAs like Incivek (telaprevir), particularly when used with peginterferon and ribavirin. Studies suggest that over 50% of users experienced a rash when exposed to this combination of drugs.

Related Skin Problems With Hepatitis C Infection

Some skin conditions share a possible association with chronic hepatitis C. For reasons not entirely clear, the risk of these is higher in people with hepatitis C than in the general population.

• Psoriasis: This autoimmune condition causes dry, raised, inflamed patches of skin covered with silvery-white scales. It is nearly twice as common in people with chronic hepatitis C as in those without.
• Dermatomyositis: This inflammatory autoimmune disease causes muscle weakness and a distinctive skin rash. In addition to a reddish-purple rash around the eyes, there may be dark red bumps on the knuckles, elbows, ankles, or knees.
• Erythema multiforme: This is a common skin reaction triggered by many different infections. It causes symmetric red, patchy skin lesions mostly on the arms and legs.
• Erythema nodosum: This is a skin symptom common in people with inflammatory bowel disease (IBD) that causes tender red bumps on larger bony surfaces on the front of the lower leg. In the absence of IBD, hepatitis C may be suspected.
• Vitiligo: This is a condition that causes the destruction of pigment-producing skin cells called melanocytes, leading to patches of abnormally light skin. Hepatitis C may be suspected if vitiligo suddenly develops during adulthood.

Skin Signs of Liver Damage 

Hepatitis C causes chronic inflammation of the liver, which over time causes progressive scarring known as fibrosis. Cirrhosis occurs when the scarring is severe enough to interfere with the function of the liver.

In rare cases, ongoing liver damage can cause cells to change at the genetic level, leading the hepatocellular carcinoma (the most common type of liver cancer).

Skin Signs of Cirrhosis

Cirrhosis not only affects the liver but also the blood and circulatory system. Abnormal blood clotting accompanied by bleeding and/or dilation (widening) of blood vessels near the surface of the skin can cause symptoms like:

• Spider angiomas: Also known as spider veins or spider nevus, these are thin reddish or purplish lines on the skin's surface that look like a spider's web.
• Petechiae: These are purplish dots on the skin caused by burst and bleeding capillaries, most often on the lower legs.
• Purpura: Also known as skin hemorrhages or blood spots, these purple-colored spots are larger than petechiae, mainly on the lower legs and ankles.

Skin Signs of Liver Cancer

Liver cancer can also cause different types of rashes, particularly if HCV is the underlying cause. These not only include previously mentioned conditions like dermatomyositis but also:

• Acanthosis nigricans: This is the darkening and thickening of the skin commonly seen in people with hepatocellular carcinoma. It is often seen in skin folds of the groin, armpits, and neck.
• Acanthosis palmaris: Also known as "tripe hands," this is the thickening of the skin of the palms accompanied by an abnormal velvety skin texture.
• Leser–Trélat sign: This is the abrupt outbreak of raised, brownish lesions called seborrheic keratoses, most commonly on the back but sometimes on the legs, arms, face, and neck. The sudden appearance of these lesions is characteristic of different cancers.

Acute vs. Chronic HCV Rash Treatment

The treatment of an HCV-associated rash varies by the stage of infection and other factors. In some cases, no treatment is needed.

Acute Hepatitis C

With acute hepatitis C, any skin-related symptom may resolve on its own over time. In fact, most acute HCV symptoms will clear within 2 to 12 weeks of their first appearance.

Even so, oral antihistamines may be prescribed to help relieve itching and hives, particularly if a condition is severe or recurrent. Cold compresses and over-the-counter (OTC) hydrocortisone cream may also help.

Chronic Hepatitis C

Treating acute hepatitis C greatly reduces the risk of a chronic infection, but because hepatitis C is often asymptomatic, the diagnosis is usually made when the disease has already progressed.

Hepatitis C is treated with a combination of direct-acting antivirals (DAAs) that are taken by mouth daily. Depending on the genetic type of virus you have, your previous history of HCV treatment, and the presence or absence of cirrhosis, the therapy can last anywhere from eight to 24 weeks.

It can be presumed that many skin-related symptoms of chronic hepatitis C will clear once you are cured of the infection. But, this is not always the case.

Depending on the skin condition and its severity, other medications may be needed, including:

• Corticosteroids (topical, oral, or injectable)
• Topical calcineurin inhibitors such as Protopic (tacrolimus ointment) and Elidel (1.0% pimecrolimus cream)
• Phototherapy (light therapy)
• Oral retinoids
• Methotrexate

Summary

Hepatitis C rashes can occur during all stages of infection and can be caused by the drugs used to treat hepatitis C. Rashes that occur during the acute stage may resolve on their own, although antihistamines, cold compresses, and hydrocortisone cream may help relieve itching and swelling.

Rashes that occur during the chronic stage may also clear once the infection has been treated with direct-acting antivirals (DAAs). Other treatments may be prescribed if needed, including corticosteroids, methotrexate, and phototherapy.

Hepatitis C drug reactions can sometimes occur and are typically mild. However, treatment needs to be stopped immediately if a drug-induced rash is severe.

A Word From Verywell

If you think you've been exposed to hepatitis C recently or in the past, it is important to get tested. Risk factors include sharing needles, having sex with someone you know or suspect has hepatitis C, or sustaining a needlestick injury.

While current direct-acting antivirals offer high cure rates at any disease stage, it is always better to get treated earlier before the liver damage has occurred. Moreover, the treatment is often simpler (with fewer drugs and shorter treatment times) if started before there is any evidence of cirrhosis.

It is important to remember that you cannot diagnose hepatitis C based on symptoms—and chances are you won't have any. The only way to diagnose hepatitis C is a blood test, including newer rapid finger-stick tests.