Hepatitis B virus (HBV)

Introduction (1)

Viral hepatitis encompasses acute and chronic liver inflammation primarily from hepatotropic viruses HAV, HBV, HCV, HDV, and HEV, producing characteristic systemic symptoms including nausea, jaundice, fatigue, and markedly elevated transaminases (alanine transaminases often >1000 IU/L).

HBV represents a partially double-stranded DNA in the Hepadnaviridae family with eight genotypes (A–H) establishing persistent infection within hepatocytes.

Epidemiology and transmission (1)

Incidence in the United States remains low for HBV, with 2,214 total cases reported in 2023 and experts estimating the actual number being around 14,400.

Chronic HBV develops in 90% of perinatally infected newborns, progressing to cirrhosis in 20% over decades with an associated increased risk for hepatocellular carcinoma. In contrast, 95% of immunocompetent adults recover completely.

Common transmission modes include childbirth, sexual contact, and needle-sharing.

Clinical features

Acute HBV manifests with prodromal fever, nausea, dark urine, and scleral icterus, progressing to generalized jaundice, making skin and mucous membranes appear yellow-green.

The cutaneous prodrome occurs in 20–30% of patients with acute HBV and includes acute urticarial or serum sickness-like morbilliform eruptions with diffuse erythematous macules coalescing on the trunk and proximal extremities, fever, headache, and joint pain.

Pediatric patients with acute HBV infection can present with Gianotti-Crosti syndrome, an eruption of symmetric monomorphic 2–5-mm erythematous papules on cheeks, buttocks, and extensor limbs, sparing the trunk and palms / soles. Lesions last days to a few weeks. (2)

Other cutaneous manifestations associated with HBV include cryoglobulinemia (acral, cold-induced signs of cutaneous or systemic vasculitis), IgA vasculitis, lichen planus, or dermatomyositis. (2)

Chronic HBV may manifest as jaundice, prurigo nodularis due to progressive pruritus, spider telangiectasias, and caput medusae.

Diagnosis (1)

• Initial evaluation includes serologic testing for three HBV sero-markers:

  • Hepatitis B surface antigen (HBsAg)

  • Antibody to hepatitis B surface antigen (anti-HBs)

  • Total antibody to hepatitis B core antigen (total anti-HBc)

Patient management and treatment

Acute HBV is generally treated with supportive care. Antiviral medications like lamivudine provide adjunctive therapy in severe acute HBV. (1)

Dermatologic management targets pruritus with emollients, topical corticosteroids, cholestyramine, and oral naltrexone, while ulcers secondary to HBV-mediated vasculitis may require compression, debridement, and skin grafts.

Prevention (4)

Universal HBV vaccination (3 doses at 0, 1, 6 months) is recommended starting at birth to prevent perinatal transmission in exposed newborns.

HBsAg screening is recommended in patients who are deemed high-risk — persons who inject drugs, men who have sex with men (MSM), and people living with HIV (PLWH) — pregnant patients, and prior to administering immunosuppressant medications. In addition, universal one-time screening is recommended by the CDC for all adults. For patients with chronic HBV, annual HBV DNA testing in individuals with cirrhosis is recommended to monitor hepatocellular carcinoma risk.