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HBV Journal Review – December 2013

HBF is pleased to connect our blog readers to Christine Kukka’s monthly HBV Journal Review that she writes for the HBV Advocate. The journal presents the
latest in hepatitis B research, treatment, and prevention from recent academic and medical journals. This month, the following topics are explored: Continue reading "HBV Journal Review – December 2013"

Diagnosed With Chronic Hepatitis B? What Phase – HBeAg-Positive Chronic Hepatitis / Immune Reactive / Immune Clearance?

In the last chronic hepatitis B stages blog, we looked at the HBeAg-Positive Chronic Infection (formerly known as immune tolerant).

At some point the immune system recognizes the hepatitis B virus and the chronically infected person will enter a phase referred to as the  HBeAg–positive chronic hepatitis- (previously known as immune reactive/immune clearance). During this phase blood work will show that you are HBeAg positive, with lower levels of HBV DNA when compared to the HBeAg-positive chronic infection/immune tolerant stage, and increased ALT (SGPT) levels. (Remember, it is not at all unusual for kids to have viral loads in the millions or even billions.) During this “clearance” phase the immune system is actively attacking infected liver cells. This is both good and bad. On the good side, if the immune system is able to “beat” the virus, the person will go through HBeAg seroconversion and lose the HBeAg antigen. This means that HBeAg will go from positive to negative and the HBeAb antibody, or anti-HBe will go from negative to positive.  This results in significant decrease in the hepatitis B virus level, often to an undetectable level, and normalization of ALT/AST liver enzymes and other liver function blood test results. Successful HBe serconversion moves you into the HBeAg-negative chronic infection/inactive carrier phase.

When the immune system activates and starts attacking infected liver cells, it not only kills the virus, but also the host liver-cells. You may not feel any of this, but your ALT (SGPT) and AST (SGOT) lab values will be elevated. These enzymes are released when there is inflammation caused by liver cells that are injured or killed.  Your doctor may see a mild, moderate or high levels of ALT elevation reflecting inflammation in the liver. Ultimately the problem is how much inflammation and liver damage occurs during the process of HBeAg seroconversion?

It is possible a person will quickly and spontaneously move into and out of the HBeAg-positive chronic hepatitis/immune reactive phase, and with a limited amount of inflammation and liver damage. However, some people may cycle up and down for years with intermittent flares, which are evidenced by ALT elevations which may be as high as 10 times above the upper limits of normal (normal is 35 IU/mL for men and 25 IU/mL for women) when in the immune reactive phase.  While the immune system attacks infected liver cells, viral replication will decrease and ALT levels will elevate as infected liver cells die in the battle.  If successful, the immune system response will result in HBe seroconversion –  losing HBeAg, gaining the HBe antibody, and a decline of the viral load  (HBV DNA) to very low or undetectable levels, and the normalization of ALT/AST and other liver enzyme levels.

Unfortunately, that might not be enough, and the immune system may not be able to put up a big enough fight permitting HBe seroconversion to a less active or HBeAg negative chronic infection /inactive carrier phase. Evidence of this is ALT levels that go back down, and viral replication that goes back up. (Note the above diagram.) This cycling up and down over time will be reflected in lab work if a liver specialist monitors you regularly over time. If you are not having your ALT levels regularly monitored (every few months), then you may miss these cycles of intermittent elevations or flares over time. It is during these elevations that liver damage occurs, and you will likely be completely unaware, unless you have lab work done while liver enzymes are elevated, or you wait until there are symptoms and significant liver damage.

It is during the immune clearance phase when treatment is sometimes recommended. It is true that a chronically infected person will eventually serconvert HBe spontaneously – without treatment, but most liver specialists choose to treat in order to prevent years of ALT elevations and flares and subsequent damage to the liver.

If you appear to be in the HBeAg-Positive Chronic Hepatitis / Immune Reactive phase, be sure you continue with regular monitoring with your doctor and don’t be afraid to ask questions about your hep B infection and the health of your liver.

 

High HBV Viral Load Tied to Low Serum Vitamin D Levels

An interesting study published in Healio Hepatology:  “High HBV viral load tied to low serum vitamin D levels” discusses the relationship between the HBV viral load and vitamin D levels. In fact is shows seasonal fluctuations of HBV viral load associated with vitamin D levels. Vitamin D has been on the radar for years, but this interesting correlation between HBV virus flucuations and vitamin D levels warrants additional research to investigate how adequate vitamin D levels can positively impact treatment for those living with chronic HBV. Please refer to earlier blogs, Hepatitis B and Vitamin D and Got HBV? Adding Vitamin D to Your Diet for additional information.  As always, please talk to your doctor and have your serum vitamin D levels checked before making any drastic changes to your diet or supplements you may be taking. Don’t forget that vitamin D is the sunshine vitamin, so be sure to keep in mind the impact of the seasons on your levels. 

Patients with chronic hepatitis B who also were vitamin D deficient had significantly higher HBV DNA levels than patients with adequate vitamin D concentrations in a recent study.

In a retrospective study, researchers measured the serum levels of 25-hydroxyvitamin D (25OHD) in 203 treatment-naive patients with chronic hepatitis B seen between January 2009 and December 2012. Patients with 25OHD levels less than10 ng/mL were considered severely deficient, levels below 20 ng/mL were considered deficient, and levels of 20 ng/mL or greater were considered adequate. Patients’ samples were collected upon initial presentation, except 29 participants whose samples were taken at antiviral therapy initiation.

The mean 25OHD concentration for the cohort was 14.4 ng/mL. Forty-seven percent of participants were considered 25OHD deficient; 34% were severely deficient. 25OHD levels were similar between Caucasians (14.38 ng/mL) and non-Caucasians (14.59 ng/mL) (P=.7).

An inverse correlation was observed between levels of HBV DNA and 25OHD (P=.0003). Multivariate analysis indicated that HBV DNA was strongly predictive of low 25OHD levels (P=.000048), and vice versa (P=.0013). Patients with HBV DNA levels less than 2,000 IU/mL had 25OHD concentrations of 17 ng/mL; those with 2,000 IU/mL or higher had concentrations of 11 ng/mL (P<.00001 for difference). Participants who tested positive for hepatitis B e antigen (HBeAg; n=26) had significantly lower 25OHD levels than HBeAg-negative participants (P=.0013); this association was significant only under univariate analysis.

Investigators also noted fluctuations in HBV DNA and 25OHD levels according to season. Significantly lower HBV DNA levels were observed among samples taken during spring or summer than in autumn or winter (P=.01).

“The present study demonstrates a profound association between higher levels of HBV replication and low [25OHD] serum levels in chronic hepatitis B patients,” the researchers wrote. “At least in patients without advanced liver disease … HBV DNA viral load appears to be the strongest determinant of low [25OHD] serum levels. … Future studies to evaluate a therapeutic value of vitamin D and its analogs in HBV infection may be justified.”

High Viral Load, HBeAg Positivity Increased Risk for Mother-to-Infant HBV Transmission

The study published by Healio Hepatology, March 8, 2013 discusses the increased risk of mother-to-infant transmission in HBV positive moms who are HBeAg positive and have a high viral load. Current prophylaxis, where infants of HBsAg+ moms receive the first shot of the HBV vaccine and a shot of HBIG within 12 hours of birth, is successful greater than 90% of the time. However, according to the study, HBeAg+ pregnant moms with a viral load above 10cp/mL(10,000,000 cp/mL) will transmit the virus to their infant despite prophylaxis. Since a particularly elevated viral load appears to determine the failure of current prophylaxis, the need for additional screening for these women and revised intervention strategies is necessary to prevent transmission to their babies at birth.

If you are a pregnant mom that is HBsAg+, please see a liver specialist for further evaluation to determine your HBeAg status and your HBV DNA viral load. If you are HBeAg + and have a high viral load, (a viral load near the 10,000,000 cp/ml threshold) you will want to talk to your liver specialist to determine if you and your baby would benefit from antiviral therapy in order to prevent transmission of HBV to your newborn. Although there are no official guidelines or recommendations, Registry data shows medications for hepatitis B appear safe during pregnancy. Talk to your doctor to see if this is a good option for you and your baby.

If you are a pregnant woman, please read and print HBF’s Chronic Hepatitis B in Pregnancy, and give it to the doctor who will be caring for you during your pregnancy. Sadly, IOM data shows HBV+ women in the U.S. are not always identified and educated about their HBV, and an opportunity for prophylaxis may be missed despite CDC recommendations that ALL infants receive the first dose of the HBV vaccine prior to hospital discharge.

If you live in a developing country, there may be no guidelines in place that automatically screen pregnant women for hepatitis B. Once again, read and print a copy of “Chronic Hepatitis B in Pregnancy” for your doctor. Insist you are screened for HBV, and if you are HBsAg+, please be sure prophylaxis will be available at the hospital where you will give birth to your baby. If you find you are HBeAg+, with a high viral load, please speak to a liver specialist to see if an antiviral is an option for you to prevent HBV transmission to your baby. Don’t’ forget to have your baby tested at 18 months to ensure your baby is HBV free.

*Please note you can convert copies per milliliter (cp/ml) to IU/mL for the article below using WHO’s international standard where 1 IU/mL = 5.2 copies/mL. Please ask your doctor or your lab if you have specific questions regarding the conversion.


Infants born to mothers with a high hepatitis B viral load, particularly those positive for hepatitis B e antigen, are at high risk for contracting hepatitis despite immunoprophylaxis, according to recent results.

Researchers evaluated 303 mother-infant pairs in which mothers tested positive for hepatitis B surface antigen (HBsAg). Maternal viral load and hepatitis B e antigen (HBeAg) status were determined, and children were tested for HBsAg at ages 4 to 8 months (n=250) and/or 1 to 3 years (n=53 for an initial test; n=183 for a follow-up test). All children received HBV vaccine within the first week of birth and at 1 and 6 months, with a 100% completion rate; children born to mothers who tested positive for HBeAg received hepatitis B immunoglobulin within 24 hours of birth.

HBeAg-positive mothers (81 cases) had higher viral loads than those who did not (7.4 ± 1.9 log10 copies/mL vs. 2.7 ± 1.4 log10 copies/mL; P<.0001 for difference). Chronic HBV infection was identified in 10 children, all born to HBeAg-positive mothers with high viral loads (range 6.5-9.5 log10 copies/mL), and all with the same HBV genotypes and subtypes as their mothers.

Investigators identified a significant association between maternal viral load and a child’s risk for infection via multivariate analysis, after adjusting for factors including age; birth type; infant gender, weight and gestational age, and feeding practices (adjusted OR=3.49; 95% CI, 1.63-.7.48 per log10 copy/mL increase). Predictive rates for maternally transmitted HBV infection were found to be statistically significant at 7 (6.6%; P=.033), 8 (14.6%; P=.001), and 9 (27.7%; P<.001) log10 copies/mL.

“High maternal viral load is the most important factor causing maternally transmitted HBV infection, and is significantly correlated with maternal HBeAg status,” the researchers wrote. “Our predictive model including multiple risk factors showed that children with a maternal viral load above 10,000,000 to 100,000,000 copies/mL (or would have a significant risk of infection despite immunoprophylaxis. Our data provide important information for the rational design of future screening and intervention strategies to further reduce maternally transmitted HBV infection.”

Wen W-H. J Hepatol. 2013;doi:10.1016/j.jhep.2013.02.015.

March 8, 2013

Diagnosed With Chronic Hepatitis B? What Stage – HBeAg-Positive Chronic Infection / Immune Tolerant?

Do you know the stage or phase of your chronic hepatitis B infection? Quite often people may refer to themselves as “hepatitis B carriers”. This statement by itself does not really say anything about your chronic hepatitis B infection except that you are someone who tests positive for hepatitis B, and that you are HBsAg positive.  The names of the stages or phases of HBV have changed a bit over the years, but they reflect the natural history of the virus. It is important for your doctor to determine if you are in the immune tolerant, immune active or clearance phase, the inactive carrier phase, have developed HBe negative chronic hepatitis B, or if you are in an HBsAg negative phase. It may take a few months or even half a year to accurately determine the phase, and then your doctor can talk to you about possible treatment options and whether or not treatment would benefit you at this time.  Remember, hepatitis B is typically not an emergency, so try to relax with the process knowing you may not have immediate answers.

If you are acutely infected, you also follow the natural course of the virus in a matter of months (clearance of an acute HBV infection within 6 months is considered an acute hepatitis B  infection). However, at the end of 6 months, those acutely infected will have a resolved infection, and will no longer be HBsAg+. If you are chronically infected, you will pass through many of these phases too, but unfortunately you will likely never get to an HBsAg negative or resolved phase.  The journey from phase to phase is different for each person and the time it takes to move through these phases varies along with the amount of liver damage that occurs. The importance of a good liver specialist or knowledgeable doctor  cannot be over emphasized. These stages and phases may seem simple to understand, but not everything is black and white, and the gray between phases, time between phases, lab and other diagnostic data collected, varies with each patient. The importance of being actively involved in your hepatitis B care can also not be overstated. Tracking your lab data over time and putting it into an excel spreadsheet or graphing the data may help you understand what is happening with the virus and may even be helpful for your doctor, so don’t forget to request copies of all lab results. You are more in control than you think. Get involved with your care!

Once you have confirmed that you have chronic hep B, you need further testing to determine your HBeAg status. Those with chronic hepatitis B  are either HBeAg positive or negative. If you are HBeAg positive, you have a higher hepatitis B viral load/HBV DNA and are more infectious to others. People who are HBeAg positive are either in the immune tolerant stage or the immune clearance stage. Additional labs will clarify this for your doctor.

If you are in the immune tolerant stage, you are HBeAg positive and have a high viral load. You will have normal or very mildly elevated ALT (SGPT) levels and mild or no inflammation or damage to the liver. This is very common with chronically infected young children who may have viral loads in the millions or even billions. During this time the virus is actively replicating in the liver, but the immune system has not recognized the virus so it is not trying to kill the infected liver cells. It is not the replication of the virus that kills liver cells, causing liver damage, but it is the response of your immune system killing these infected liver cells.  So, during the immune tolerant phase the virus is happily replicating, completely unchecked by the immune system, which accounts for the high viral load and lack of liver damage during this time. People in the immune tolerant phase may remain in this phase for a couple of years, or it may be decades.  Treatment is not typically recommended during this phase.  Certainly for those that have been in this phase for decades, treatment is something that may be recommended by your liver specialist.

What happens when you move into the HBeAg-positive chronic hepatitis /Immune Reactive / Immune clearance  phase? Read more. 

Why Give the Hepatitis B Vaccine to Infants?

The CDC recommends a birth dose of the hepatitis B vaccine for all babies. Pediatrician, Dr. Allison Shuman explains why in this informative video.

If you live in a part of the world where chronic HBV is at a medium (2-7% of population) or high prevalence rate (greater than 8% of population), your child is especially susceptible and at-risk for hepatitis B, with HBV transmission often occurring vertically from mother to child at birth, and horizontally from an HBV infected adult or another child’s infected body fluids to an unvaccinated baby or child. Please be sure that pregnant women are screened for hepatitis B. If mom tests positive for HBV, be sure baby receives a birth dose of the HBV vaccine and a shot of HBIG within 12 hours of birth. If mom tests negative for HBV, be sure that baby receives a birth dose of the HBV vaccine before leaving the hospital. Both babies of HBV infected and uninfected mom’s should receives shots 2 and 3 of the series according to schedule. Babies of infected mom’s should be tested at 18 months to be sure baby is hepatitis B free.

Please make arrangements with your doctor and the hospital to receive the HBV vaccine for your baby, prior to delivery, so you are sure the vaccine and/or HBIG are available at the hospital so prophylaxis can be given within 12 hours of birth. Please feel free to print and distribute  Chronic Hepatitis B in Pregnancy: Screening, Evaluation and Management (Part I and Part II) to your doctor.

 

Hep B Parents: 10 Reasons You Should Get Yourself to Philly

Attention parents of children living with Hepatitis B. Please join the Hepatitis B Foundation for it’s “2012 B Informed Parent Conference“, Saturday May 19th in Philadelphia. It’s going to be an incredible program filled with expert, pediatric guest speakers. It’s also a wonderful opportunity for parents to meet face-to-face to talk about raising kids with HBV.  Think about it, clear your schedule, register, and join us for the day. And if that isn’t enough, here are 10 Reasons You Should Get Yourself to Philly, expressed by Eileen, a good friend of HBF…

1. The “B Informed” Conference for parents of children with Hepatitis B happens just once a year. You do not want to miss this.

2. You will get answers. No matter where your child is on the spectrum, I know you’ve got questions. You’re going to get those questions answered. This isn’t a doctor’s appointment, there isn’t a waiting room full of patients, the doctor’s hand isn’t already on the doorknob. Ask all the questions you want to ask and ask until the lightbulb turns on and you get it. You’ll go home a more confident, better informed advocate for your child.

Read more…

Many Parents Request Delays in Vaccine Schedule -Why the HBV Vaccine is Important for Infants and Young Children

Last week’s report of a recent study shows that more parents are opting out or delaying some vaccines for their children, and the hepatitis B vaccine is one of those parents sometimes choose to skip or delay.  What is even more disappointing is that the majority of pediatricians polled were comfortable with an alternative HBV vaccine schedule for their young patients.

The unfortunate thing about HBV is that it is very effectively passed from an HBV infected mother to her child during the birth process. Children that are infected with hepatitis B at birth, or as a baby, have a 90% chance of being chronically infected for life.   Young children that are infected horizontally have up to a 50% chance of being chronically infected for life. Children living with HBV are typically highly infectious and very effective at unknowingly spreading the virus to little friends or family members. HBV is present in blood and body fluids and we all know how kids are fascinated by one anothers’ boo-boos, and half of them have some sort of rash or scrapes that are tough to keep covered at all times. The beauty of vaccination is that infants and little ones are protected when they are at day care and pre-school, and when they are playing with the neighborhood kids.  Protocols are in place, but accidents do happen and rules are not always followed. You may think your child’s world is HBV free, but but you may be wrong.  Is it worth the risk when there is a safe and effective vaccine available?

Later in life, HBV is effectively transmitted horizontally in the mode that is often associated with infectious disease – sexually.  We are all sexual beings and at some point sex will become part of our lives.  Will you be thinking about having your teen or college student vaccinated, or will you be like most of us and too busy to even think about it?  What about when your teen or college student comes home with a tattoo or body piercing they got at a bargain tattoo/piercing parlor?  No one likes to think about their children making impulsive decisions, but the reality is that most do.  They have lapses in judgment and they make mistakes. A parent can only control so much, but why not eliminate the chance of HBV infection later in life?

You might think you will deal with HBV if you are faced with it. Even if your child is infected, or playing with a child that is infected, there will be no notable symptoms.  That’s why they call it a “silent infection“. Your liver is a non-complaining organ so symptoms rarely appear unless your liver is in distress. HBV will likely go unnoticed for decades unless it is picked up with routine blood work, during a blood donation, or a blood screening. That doesn’t mean liver damage is not occurring over decades of infection.

Our world keeps getting smaller, and travel to exotic lands is common. The U.S. is a melting pot of countries around the globe – many where HBV is prevalent.  Do you know that 2 billion people in the world have been infected with hepatitis B and that 400 million are living with a chronic, life-long infection? That is 1 out of 3 people in our world that have had an HBV infection!  There are good treatments out there, but there is no complete cure.  Many live long, lives, but lifelong HBV puts you at high risk for advanced liver disease, liver cancer and death.  The stigma associated with HBV leaves many throughout the world unemployable, and even those in the U.S. may suffer from discrimination and judgment by others due to their disease.

People write to HBF and tell us their HBV story.  Many have no idea how they were infected.  It is not casually transmitted, but it is an infectious disease – 50 to 100 times more infectious than HIV and 5 to 10 times more infectious than HCV.  The U.S. is fortunate to have a vaccine available to all children born in this country. Parents worldwide would give anything to have their infant vaccinated to prevent a lifetime with HBV.  Some countries have HBV vaccine shortages.  Many cannot afford the vaccine, and many are unaware of the vaccine until they learn they are infected. In the U.S. we have an opportunity to prevent a life-long infection with HBV with a simple vaccine.  Please don’t choose to delay or omit the hepatitis B vaccine from your child’s vaccine schedule.

Living with HBV and Dealing with “Itchy” Skin

The previous Hepbtalk blog discussed skin manifestations associated with hepatitis B and liver disease. This is a follow-up with some suggestions on dealing with rashes and pruritus (itchy) skin. Unfortunately, I have experience with this.

Most people living with HBV have episodes with rashes that itch, or with an itch without the rash. Rashes can be caused by all kinds of things, but the skin truly does let us know when there is something going on with our body. We may not be able to eliminate the itch, but we can work on providing the body with a little relief, and to be sure we do not do anything to make the persistent itching worse.

First, consider the root of the problem. It is possible that your rash and itching are unrelated to the current status of your HBV infection.  Unless you have serious liver disease, this might be difficult to pin down since many living with chronic HBV have compensated livers that perform all of the necessary liver functions required for life.  That does not mean you aren’t going crazy with itchy skin, but it is important to look at other factors that may be contributing to your pruritus.

  • Are you currently being treated with IFN or PEG for your HBV?
  • Have you recently started a new medication?
  • Do you have allergies, seasonal, food or otherwise?
  • Do you have other symptoms that might relate to another virus or infection?
  • Have you recently switched laundry detergents or rinses?
  • Have you recently switched any of your personal care items – shampoo, soap, creams, deodorant, etc.

Try to determine if there is a pattern associated with your skin problems.  Any of the above can cause rashes or pruritus without the added complication of HBV or advanced liver disease from HBV. I was convinced that HBV was the root of all skin problems, but I was wrong. That’s why it’s good to look at other possible sources so you can at least eliminate the things you have control over.

Here are some simple things you can do to help reduce the degree of pruritus:

  • Choose products that are unscented including laundry detergent and dryer sheets, along with shampoos, conditioners, creams and other personal care items. Unscented products are better for you liver, anyway. Everyone in my house is clean, but there is no fresh, clean smell.
  • Avoid soaps and use gentle skin cleansers like Cetaphil (another favorite in our house).
  • Use moisturizers that contain a minimum of alcohol, since alcohol is drying.  There is sometimes a balance with thick vs. thinner creams. We bounce back and forth between Cetphil and Eucerin, but you might have to test a few of them before you find the one that works best for you.
  • Take tepid rather than hot showers and baths, but be sure to bathe daily.
  • Wean your kids out of the tub ASAP.  This broke my heart, but the extra time in the bath is drying.  (However, oatmeal baths are recommended, even though this didn’t work for us). Don’t spend too long in the shower.  Learn to take a 5 minute shower.
  • When you come out of the shower, do not completely dry yourself, and immediately apply gentle cream or lotion from head to toe to lock in the moisture.
  • Use topical steroids in order to combat affected skin patches.  For kids we found the ointment, though a little messier, was more effective. Take care when topicals are used for extended periods of time.  It thins the skin, which can be especially problematic in the summer. Don’t forget sunscreen, too!
  • Keep nails cut short to avoid the temptation.  We even tried gloves and socks at night.  Try to avoid scratching with sharp objects, but be sure to properly sanitize them if they are used inappropriately. We often had concerns with “weepy” skin and needed to keep it covered in public.
  • If you choose to add humidity during the winter months be careful to balance that with possible dust mite allergies.  We initially used warm mist humidifiers and that was a big mistake, even though it feels great.  Unfortunately it took us a while to make that link.  As it turns out, a more moderate temperature is better – that and additional circulation with a ceiling fan.
  • Stay hydrated by drinking plenty of water
  • After swimming in a chlorinated pool, be sure to rinse immediately and apply moisturizer.
  • Pruritus is worse at night, so take an anti-histamine like Benedryl or prescription Atarax to help with the itching.  Atarax is effective for a longer period of time, so it’s a favorite in our house.

Although the “itching” in our house brought many tearful nights, and nasty looking skin patches that persisted for years, it did get better over time, with changes. It is important to note that is was much worse during treatment with interferon. Pruritus truly is a horrible, sometimes unrelenting symptom for those with more advanced liver disease.  Although the above ideas are worth investigating, it is important that you discuss severe pruritus with your doctor.  There are more potent prescriptions available that might help reduce the relentless itching.

Got any tips for reducing the itch? Feel free to comment and share your ideas with others living with HBV.

Got HBV? What is Your Skin Trying to Tell You?

The liver is the largest solid organ in the body, and your skin is the largest organ.  It only makes sense that the skin may be a window into what is going on inside your body and your liver.  The problem is trying to figure out what your skin is trying to tell you!

The most common skin manifestation associated with “hepatitis” is the yellowing of the skin (jaundice) and the sclera, or white part of the eye.  Jaundice  may be associated with a newly acquired or acute hepatitis B infection.  It certainly gets your attention and gets you to the door of your doctor, which is a good thing.  However, keep in mind that HBV is often asymptomatic, with few or no obvious symptoms, and jaundice is a more severe symptom of an acute HBV infection. Jaundice may also occur in those with advanced liver disease, and a decompensated liver. Jaundice is due to an accumulation of bilirubin, a yellow pigment, in the blood and tissues.  Your liver is responsible for controlling the levels of bilirubin.  If your liver is having problems performing basic, yet essential functions, yellow skin, eyes, dark urine, and itching (pruritus) may all be due to an inability to filter excess bilirubin.  Please see your doctor immediately if you experience jaundice of the skin or eyes.

It is also not uncommon for those with more advanced liver disease such as cirrhosis to have palmar erythema, which presents like red palms –especially around the base of the thumb and little finger.  Keep in mind that there may be other reasons for experiencing red palms, such as high blood pressure, pregnancy, or elevated estrogen levels. Talk to your doctor if you have concerns.

Spider nevi or spider angioma are another indicator of more serious liver disease. These are not to be confused with spider veins. It is also important to note that 10-15% of healthy adults and children have spider nevi, with no underlying disease. They range in size from 0.5 to 1 cm in diameter, with a dark center, radiating out to fine, red lines. When the center is depressed with the finger, the radiating lines disappear, and then re-appear, when the finger is lifted. Spider nevi may be caused by an increased level of estrogen in the body.  Naturally these may also appear during pregnancy, and in women using oral contraceptives. Following pregnancy and the discontinuation of contraceptives, the spider angiomas will disappear on their own. Like so many basic, but essential functions, the liver is responsible for breaking down and removing excess estrogen. Spider nevi associated with liver disease tend to be large in number and appear on the upper part of the body, face, and neck – especially on the backs of the hands and arms. Once again, it is a good idea to point out these out to your doctor.

Gianotti-Crosti Syndrome is a rash associated with HBV and EBV (Epstein Barr Virus). This rash almost always occurs in children, with 90% of kids under the age of four. The rash may last from two to eight weeks. Basically, it’s just a response to a virus, and nothing to worry about – just an indicator. Kids often have a rash for one reason or another.  If the rash is excessively itchy, talk to your pediatrician about using a topical steroid. Every parent of a child with HBV is convinced their child has some sort of HBV associated rash. (Speaking from experience…) Even the pediatric liver specialist was unsure, so she got a consult with a pediatric dermatologist.  The rash was unrelated to HBV.

Wondering about your finger nails?  There’s a condition called Terry’s Nails which is present in many of those with cirrhosis. The nail appears mostly white, similar to the appearance of “ground glass”, and possibly with a little pink strip at the top of the nail bed.  This is due to a decrease in blood flow to the nail bed and an increase in connective tissue.  Remember that your doctor will not be able to see any of this if you wear nail polish to your appointment.

How about your basic rash that is associated with hepatitis B?  Rashes are most often associated with acute hepatitis B infections, although a recurring rash may occur in those chronically infected.  Talk to people living with HBV and they’ll tell you they have occasional rashes and annoying itching, even if their doctor may tell them they do not.  Could be totally unrelated, or it could be erythematous papular lesions, or palpable purpura.  In other words, your basic red or purplish, raised, bumpy rash. It’s not easy to find specific information linking your basic rash to HBV, but when you consider how the skin is a window to your general health, it makes sense that you may see skin manifestations that reflect your immune system response to your HBV infection as it cycles through various stages, phases and flares.

If you are living with HBV, you know the importance of monitoring your HBV status and your liver health.  Annual, bi-annual, or the schedule recommended to you by your liver specialist, will keep you on top of what is going on with your HBV and any associated liver disease.  However, it is good to take notice of any changes in the skin and nails as the liver is a non-complaining organ.  Sometimes we have to look for evidence that something is going on. That being said, I feel the need to rush to a mirror and check myself out after having researched and written this blog.  The skin may be a window to our general health, but it is not always easy to figure out what it’s trying to tell us. If you have any questions, don’t try to self-diagnose. Talk to your doctor and bring any of your concerns to his attention.