Pruritus with or without cholestasis in hepatitis C

Prof. Dr. med. J. Reichen

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• Pruritus is a frequent symptom of hepatitis C, being found in between 2.5 and 15 % of patients (2, 3, 6); it can be the presenting symptom of hepatitis C (4, 6). Compared to other liver diseases, pruritus occurs in a higher proportion of patients (15 vs 4 %; 2). Interestingly, in uremic patients on CAPD viral hepatitis is associated with a higher prevalence and higher intensity of pruritus (5).
• In the larger series, pruritus is associated with elevated ALT in all patients (1, 3). Moreover, it is generally seen in patients with more advanced histological lesions (1, 6), in one study comparing hepatitis C with and without pruritus cirrhosis being present in 66 vs 8 % (7).
• The role of cholestasis is less clear: alkaline phosphatase is elevated in ~50 % only (1) and g-GT in 60 - 85 % (1, 3). Bile acids are elevated in a substantial number where they have been measured (1). In some patients, pruritus is associated with typical bile duct lesions and even ductopenia (1, 7).
• There a variety of skin disorders in hepatitis C associated with pruritus (2, 3): eczema-like lesions (41 %), urticaria (19 %), lichen planus (4 %), cryoglobulinemia (4 %) and atopic dermatitis (7 %).
• The pruritus is often fluctuating and response to topical and antiviral treatment is inconsistent (3, 7).

References:

1. Chia SC, Bergasa NV, Kleiner DE, Goodman Z, Hoofnagle JH, Di Bisceglie AM. Pruritus as a presenting symptom of chronic hepatitis C. Dig Dis Sci 1998; 43(10):2177-2183.
2. Cribier B, Samain F, Vetter D, Heid E, Grosshans E. Systematic cutaneous examination in hepatitis C virus infected patients. Acta Derm Venereol 1998; 78(5):355-357.
3. Dega H, Frances C, Dupin N, Lebre C, Simantov A, Callot C et al. Pruritis and the hepatitis C virus. The MULTIVIRC Unit. Ann Dermatol Venereol 1998; 125(1):9-12.
4. Fisher DA, Wright TL. Pruritus as a symptom of hepatitis C. J Am Acad Dermatol 1994; 30:629-632.
5. Hung KY, Shyu RS, Tsai TJ, Chen WY. Viral hepatitis infection should be considered for evaluating uremic pruritus in continuous ambulatory peritoneal dialysis patients. Blood Purif 1998; 16(3):147-153.
6. Kumar KS, Saboorian MH, Lee WM. Cholestatic presentation of hepatitis C  A clinical and histological study with review of the literature. Dig Dis Sci 2001; 46: 2066-2073
   
7. Lebovics E, Seif F, Kim D, El Hosseiny A, Dworkin BM, Casellas A et al. Pruritus in chronic hepatitis C - Association with high serum bile acids, advanced pathology, and bile duct abnormalities. Dig Dis Sci 1997; 42(5):1094-1099.

January 6^th 2001
Revised August 26^th 2009