This adolescent boy with a history of Hepatitis C virus infection with hepatic fibrosism hypertension, and thronbocytopenia developed a pruritic eruption on his face, trunk, genitals, and extremities with a predilection for bony prominences. He failed to respond to multiple topical therapies including mid and high potency topical steroids, antihistamines, topical barrier repair creams, narrow band ultraviolet B light therapy, and tar baths. He was also given oral zinc for borderline low serum zinc levels. A skin biopsy showed a nonspecific psoriasiform dermatitis consistent with necrolytic acral erythema. Hepatitis C virus RNA polymerase chain reaction studies showed 974,000 IU/mL (<50) and HCV RNA genotype 1b.
symmetric acral thick confluent hyperpigmented and crusted papules and plaques