Liver Disease Rash

What is Liver Disease?

Liver disease encompasses a wide range of conditions that progressively cause deterioration of liver tissue and function. Liver disease is caused by a wide range of health conditions caused by several risk factors. Alcohol-related liver disease is a type of liver disease that is caused by sole overconsumption of alcoholic beverages. Non-alcoholic fatty liver disease has several risk factors, such as obesity and an unhealthy diet. Hepatitis caused by a viral infection can lead to liver disease. Liver disease causes the gradual deterioration of the liver leading to liver failure, which can be life-threatening. However, if liver disease is detected early, many of the adverse side effects can be prevented.  

Cirrhosis

Cirrhosis is a late-stage form of liver disease that is characterised by the formation of liver scar tissue due to the continued advancement of liver disease progression.1 Healthy liver tissue is replaced with fibrotic scar tissue causing permanent damage to the liver and loss of liver function. The scar tissue formation causes a block of blood flow through the liver, causing a reduced exchange of nutrients and waste products.2 Scar tissue formation also results in reduced production of liver-derived proteins such as bile, which breaks down food. Cirrhosis is life-threatening as it inhibits the liver’s essential functions, such as blood filtering, cholesterol synthesis, bile synthesis, and blood plasma proteins.1 

Symptoms

Cirrhosis symptoms do not typically present until liver damage becomes significant. Cirrhosis symptoms can include:1-3

  • Weakness
  • Nausea
  • Sudden Weight Loss
  • Fluid accumulation in the abdominal area (Ascites)
  • Absence of period in women
  • Lack of sex drive in men
  • Itchy skin
  • Jaundice of the skin and eyes
  • Hepatic encephalopathy: Neurological Complications
  • Enlarged breasts in men
  • Swelling in arms, ankles, and feet
  • Bruising of the skin
  • Dark pee
  • Memory loss
  • High temperature
  • Shivering
  • Pale-coloured faeces 

Causes and Risk Factors

There are several health conditions that can cause substantial liver damage to develop into cirrhosis. These conditions include:

Viral hepatitis B, C, and D: Viral hepatitis conditions cause inflammation of the liver resulting in liver tissue damage. Although each viral hepatitis condition is different, they all can lead to cirrhosis development if not treated early.3 

Alcohol Abuse: The liver is the primary site of alcohol metabolism in the body. Chronic overconsumption of alcohol causes damage to the liver cells leading to the characteristic scar tissue formation of cirrhosis.2 

Haemochromatosis: a genetic condition in which iron accumulates in the body over several years due to over-absorption of dietary iron.  High iron levels have toxic effects which cause significant damage to the liver and other organs.4,6 

Wilson’s Disease: a genetic condition in which copper accumulates in the body in a variety of tissues, including the liver. High copper levels are toxic to the body’s cells which over time leads to cirrhosis development, neurological conditions, and osteoporosis.3 

Alagille Syndrome: a genetic disorder in which bile produced by the liver accumulates within the liver due to not enough bile ducts for efficient bile drainage. Bile accumulation can progress to liver damage resulting in cirrhosis development.4  

There are several risk factors that can lead to the incidence of liver cirrhosis. These include:4

  • Viral hepatitis: Inflammation of the liver caused by a viral infection can increase an individual’s risk of cirrhosis  
  • Fungal and parasitic Infections: Fungal and parasitic infections can cause significant liver damage leading to cirrhosis development 
  • Use of shared needles: Sharing needles is one of the ways that hepatitis is transmitted through contact with the blood of an infected individual
  • High lipid levels in the blood: High-fat levels are the early stages of liver damage preceding cirrhosis development.  High-fat levels lead to characteristic scar formation of cirrhosis 
  • Diabetes: Patients with Type 2 diabetes have a high risk of cirrhosis due to the liver’s reduced response to insulin which causes the development of type 2 diabetes
  • Smoking: Carcinogens and harmful substances in cigarette smoke can cause significant to lead cirrhosis 
  • Gender: People assigned female at birth (AFAB) are more susceptible to liver cirrhosis than people assigned male at birth (AMAB)  due to hormonal differences 

Treatment

The extent of a patient’s liver damage determines the treatment method. Cirrhosis treatment aims to slow the liver scar tissue formation progression to maintain liver function and prevent further complications from arising.

If cirrhosis is detected early, the treatment method involves trying to minimize the patient’s specific risk factor(s). If cirrhosis development is alcohol-related, patients are encouraged to stop drinking alcohol through programs such as rehab.4 Stopping the consumption of alcohol can stop the progression of scar tissue and maintain liver function.  In non-alcohol-related liver disease, weight loss is typically encouraged to reduce the body’s lipid levels.  In hepatitis-derived cirrhosis, antiviral medications are typically administered to prevent further liver tissue damage.5 

In advanced cirrhosis patients, liver damage may progress to liver failure, defined by full loss of liver function. Liver function cannot be regenerated, so a liver transplant is the final option. Liver transplant surgery involves replacing a damaged liver with a healthy liver from a deceased donor or a section of the liver from a living donor. For this procedure to occur, advanced cirrhosis patients must be determined fit enough to survive the surgery and post-operative recovery. It is reported that patients with alcohol-derived cirrhosis have similar post-transplantation survival rates to non-alcoholic cirrhosis patients.3 These patients must also commit to lifelong abstinence from alcohol.

However, future treatment methods for cirrhosis are looking quite promising through current research on the potential uses of stem cells to reprogram and reset liver cells to reverse fibrosis and scar tissue formation. Researchers are currently conducting clinical trials to examine the potential useful properties of stem cells in a wide range of liver conditions.12

Hepatitis C

Hepatitis C is inflammation of the liver caused by the hepatitis C virus. It is a significant type of viral hepatitis as there is currently no vaccine that works against the condition.5 Viral hepatitis C survives in the patient’s blood resulting in common transmission methods such as sharing of unsterilized needles, unprotected sex, recreational drug use by injection, and unsafe blood transfusions. Patients with hepatitis C can have acute or chronic symptoms; acute hepatitis C may last up to six months, while the chronic form cannot be cleared from the body.5  About over half of all acute hepatitis C patients develop chronic hepatitis C.5   According to the WHO, an estimated 58 million people have hepatitis C virus.13 An average of 1.5 million new cases occur each year.13

Symptoms

Hepatitis C symptoms share common symptoms with other liver conditions including cirrhosis and fibrosis, these include:

  • Easily bleeding
  • Easily bruising
  • Skin rash/Itchy skin
  • Lack of appetite
  • Nausea
  • Abdominal fluid buildup (Ascites)
  • Sudden Weight Loss
  • Hepatic encephalopathy: confusion, brain fog, slurred speech
  • Jaundice
  • Abdominal pain
  • Vomiting
  • Abnormal coloured faeces (straw-coloured, clay, etc.)
  • Dark yellow urine8

Hepatitis C infection is initiated with acute hepatitis C; however, this usually goes undiagnosed as acute hepatitis C rarely causes clinical symptom presentation. Acute symptoms typically take up to three months after viral exposure to appear and may last up to three months.8,9 

Causes and Risk Factors

Hepatitis C infection is caused by an individual becoming infected with the hepatitis C virus through having some form of contact with the blood of an individual infected with hepatitis C.10  It is recorded that there are seven distinct forms of hepatitis C virus each with different characteristics and geographical distribution. The NHS reports that the most common forms of hepatitis C virus are strain 1 and strain 3.5 One can become infected with hepatitis. Hepatitis C virus is commonly transmitted through the practice of unsafe sex methods, the use of unsterilized and/or shared needles, blood transfusions (if not thoroughly screened), and operations done in unsterile conditions.5 

There is a wide range of risk factors that increase an individual’s risk of hepatitis C virus.  These include:

  • Injection of recreational drugs such as heroin through unsterilized and/or shared needles.
  • Being infected with HIV.9 
  • Piercings or tattoos performed in an unsterile environment (e.g., with unsterile instruments).
  • If an individual’s mother had hepatitis C at the time of one’s birth.9  
  • Individuals of the Baby Boomer generation (1045-1965) have the highest incidence of hepatitis C infection.9
  • Undergone blood transfusion or organ before 1992.9 

Treatment

Hepatitis C is treated using antiviral medications, there is currently no vaccine for hepatitis C.5 If hepatitis C is detected early, treatment is typically not initiated right away. Blood tests may be performed a few months following detection to determine if the immune system is able to clear the virus. If the infection persists several months following diagnosis, it is then classified as chronic hepatitis, which does require treatment.5 

Chronic hepatitis C patients take direct-acting antiviral tablets. These tablets are the most effective medications against chronic hepatitis C while also the safest. This type of antiviral medication is able to clear the viral infection in over 90% of hepatitis C virus patients. Treatment duration is typically 8-12 weeks; however, it ultimately depends on the patient’s hepatitis C virus form.

The following are examples of NHS-approved hepatitis C medications:

  • Sofosbuvir
  • Ribavirin
  • Elbasvir and grazoprevir (combined)
  • Combination of sofosbuvir and velpatasvir5  
  • A small minority may experience severe side effects from hepatitis C infections that include skin irritation and skin rash
  • Anxiety
  • Changes in mood and behaviour; increased aggression
  • Fatigue due to anaemia5  

Skin Effects of Liver Damage

Itching

Itching is a common symptom in a wide range of liver diseases; however, it is rare in alcoholic liver disease and fatty liver disease.10 Itching in liver disease is commonly associated with damage to bile ducts, such as damaged bile ducts in primary biliary cirrhosis, inflammation of the bile ducts in cholangitis, and bile buildup in intrahepatic cholestasis in pregnancy.10 Currently, there is no clinical explanation for the cause of itching in liver disease. Current theories suggest that individuals with liver disease may have higher bile salt accumulation within the skin that may cause itching. In pregnancy, changes in female sex hormones in pregnancy or hormone replacement therapy increase itchiness.10 

Jaundice

Jaundice occurs when the liver is unable to remove bilirubin, a waste product of the blood from blood. Due to bilirubin’s yellow pigment, bilirubin accumulation in the blood causes yellowing of the skin and eyes and darkening of the patient’s urine. Jaundice is typically a sign of liver or bile duct damage.10 

Lichen Planus

Lichen planus is a skin condition that is characterised by inflammation of the skin and mouth. It typically presents as itchy, painful bumps around the mouth, skin, nails, oesophagus, urinary tract, and vagina. Lichen planus is often caused by hepatitis C, medications used to treat cardiovascular conditions, and autoimmune conditions. Lichen planus is not contagious and can typically be treated without serious medical intervention.11 

Necrolytic Acral Erythema (NAE)

Necrolytic acral erythema is a condition that is a well-known indicator of hepatitis C virus infection. The condition presents as the formation of bumps on the skin of the toes and the feet. Researchers believe that there are several genetic and environmental factors that cause the condition, including zinc deficiency, poor liver function and low levels of liver-produced proteins such as albumin in the blood.  It can be treated with zinc supplementation and hepatitis C treatment.11 

Porphyria Cutanea Tarda (PCT)

Porphyria cutanea tarda is a rare condition in which painful skin lesions prone to blistering are formed following sun exposure. Porphyria Cutanea Tarda is caused by a deficiency in enzymes which then affects the liver. It may cause an accumulation of fat and iron in the liver and scarring of the liver’s veins.11 

Purpura

Purpura is a skin condition in which purple-coloured spots form on the skin, organs and mucous membranes such as the inside of the mouth. Purpurea is characterised by small blood vessels bursting to cause the pooling of the blood under the skin.  Many Hepatitis C patients may present with this condition, suggesting the virus is associated with Purpura.

Spider Angiomas

Spider angioma is a condition that is characterised by a small blood vessel clustering close to the skin surface. Spider angioma can form due to sun exposure, hormonal changes, and liver disease. It is a common sign of liver disease due to changes in blood flow due to scar tissue formation in hepatitis C virus.10,11 

Urticaria

Urtica is commonly known as hives and often is considered a sign of hepatitis. In hepatitis-related, hives last more than a few hours and may leave behind a brown stain. Doctors typically treat urticaria with antihistamines medication.10,11 

Skin effects of Hepatitis Medication

Despite hepatitis medication working in 90% of hepatitis C patients, it causes a diverse range of skin conditions such as rash and alopecia. Alopecia from hepatitis C is very rare, but there have been several occurrences.11  

Summary

​​Liver disease is a diverse range of liver conditions that share many different common symptom types. Risk factors such as chronic alcohol abuse, fat accumulation and a diverse range of genetic conditions predispose individuals to liver disease.1-3 Hepatitis C virus is a condition in which the hepatitis C virus causes liver inflammation and is transmitted from direct blood contact with an infected individual. Hepatitis C causes a wide range of skin formation due to liver-induced changes in blood vessel formation and location. Although there are antiviral medications to treat hepatitis C, there is currently no vaccine for the condition.5 

References 

  1. ​​NHS. Non-Alcoholic Fatty Disease [internet]. 2022 [cited 2022 May 12]. Available from: https://www.nhs.uk/conditions/non-alcoholic-fatty-liver-disease/
  2. Mayo Clinic. Liver Disease [internet]. 2022 April 08 [cited 2022 May 12]. Available from: https://www.mayoclinic.org/diseases-conditions/liver-problems/symptoms-causes/syc-20374502
  3. Mayo Clinic. Cirrhosis [internet]. 2021 February 06 [cited 2022 May 12]. Available from: https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487.
  4. Cleveland Clinic. Cirrhosis of the Liver [internet]. 2020 November 01 [cited 2022 May 12]. Available from: https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver
  5. NHS. Hepatitis [internet]. 2019 February 04 [cited 2022 May 12]. Available from: https://www.nhs.uk/conditions/hepatitis/
  6. NHS. Haemochromatosis [internet]. 2019 November 14 [cited 2022 May 13]. Available from: https://www.nhs.uk/conditions/haemochromatosis/
  7. Watson B.  Risk Factors and Potential Complications [internet]. [cited 2022 May 13]. Available from: https://www.mymed.com/diseases-conditions/cirrhosis/risk-factors-and-potential-complications-of-cirrhosis
  8. Davis K, Sherell Z. What to Know About Hepatitis C [internet]. 2021 November 28 [cited 2022 May 13]. Available from: https://www.medicalnewstoday.com/articles/294705
  9. Mayo Clinic. Hepatitis C [internet]. 2021 August 31 [cited 2022 May 14]. Available from: https://www.mayoclinic.org/diseases-conditions/hepatitis-c/symptoms-causes/syc-20354278
  10. Pietrangelo A. What Causes Itching in Liver Disease How to Treat It [internet]. 2019 September 30 [cited 2022 May 13].  Available from: https://www.healthline.com/health/liver-disease-and-itching
  11. Wheeler R. Symptoms of Hepatitis C on Skin, Hair, and Nails [internet]. 2022 January 19 [cited 2022 May 13]. Available from: https://www.webmd.com/hepatitis/hepatitis-c-skin-problems
  12. Tsolaki E, Yannaki E. Stem cell-based regenerative opportunities for the liver: State of the art and beyond. World J Gastroenterol [Internet]. 2015 Nov 21 [cited 2022 Aug 9];21(43):12334–50. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4649117/
  13. Hepatitis c [Internet]. [cited 2022 Aug 9]. Available from:  https://www.who.int/news-room/fact-sheets/detail/hepatitis-c

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Brianna Jacobs

Bachelor of Science - BS, Biomedical Sciences, General, University of Birmingham, England
Brianna is a Second Year Biomedical Science Student who experienced Medical Writing Intern.

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