Lack of classic histology should not prevent diagnosis of necrolytic acral erythema

We describe a patient who was referred for management of psoriasis unresponsive to treatment. Given the predominantly acral distribution of the patient's rash and his known diagnosis of hepatitis C, we considered the diagnosis of necrolytic acral erythema (NAE) and empirically began treatment with oral zinc sulfate. At follow-up 3 weeks later, the patient had exceptional improvement in his cutaneous disease, supporting our diagnosis of NAE. NAE is a recently described entity, and limited information is known regarding its etiology and pathogenesis; however, previous reports have been fairly consistent regarding the clinical and histopathologic presentation. We describe a patient without the classic histologic or clinical findings of previously described cases of NAE. We believe that it is important to keep the diagnosis of NAE in one's differential for a predominantly acrally distributed rash. Furthermore, we recommend additional work-up, including hepatitis C status and zinc levels, as well as possible treatment with oral zinc sulfate in patients with a potential diagnosis of NAE.