Porphyria cutanea tarda is the most common porphyria and causes blistering and fragility of skin exposed to sunlight.
People have chronically recurring blisters on the sun-exposed areas of their bodies.
Excess iron can build up in the liver, causing liver damage.
Doctors test urine and stool samples for high levels of porphyrins.
Porphyrias are a group of disorders caused by abnormalities of enzymes involved in the production of heme. Heme is a chemical compound that contains iron and gives blood its red color. Heme is a key component of several important proteins in the body. (See also Overview of Porphyria.)
Porphyria cutanea tarda occurs throughout the world. There are two main types:
Type 1: Acquired or sporadic (in about 75 to 80% of people)
Type 2: Hereditary or familial (in about 20 to 25% of people)
As far as is known, the sporadic form of this porphyria is the only porphyria that can occur in people who do not have an inherited deficiency of an enzyme involved in heme production.
Porphyria cutanea tarda results from underactivity of the enzyme uroporphyrinogen decarboxylase, which leads to accumulation of porphyrins in the liver. Liver disease is common. About 35% of people develop cirrhosis and 7 to 24% develop liver cancer. Skin damage occurs because excess porphyrins produced in the liver are transported by the blood to the skin.
Porphyria cutanea tarda has several common precipitating factors. These factors include
Excess iron in the liver
Moderate or heavy alcohol use
Smoking
Taking estrogens
Infection with hepatitis C virus
Hepatitis C infection is a major risk factor for development of porphyria cutanea tarda, and it should be looked for in all patients with this disorder. If present, the initial treatment of choice is direct-acting antiviral medications to cure hepatitis C virus infection, which will nearly always also lead to remission of porphyria cutanea tarda.
Infection with the human immunodeficiency virus (HIV) is a less common precipitating factor.
These factors are thought to interact with iron and oxygen in the liver and thereby inhibit or damage the enzyme uroporphyrinogen decarboxylase.
Some people receiving hemodialysis for long periods develop a skin condition that resembles porphyria cutanea tarda because dialysis does not remove porphyrins well. This condition is termed porphyria cutanea tarda of end-stage renal disease.
Pseudoporphyria
Kidney failure, ultraviolet radiation (UVA), and certain medications can cause symptoms that resemble those of porphyria cutanea tarda without elevated levels of porphyrin in the liver (a condition called pseudoporphyria).
Symptoms of Porphyria Cutanea Tarda
People with the sporadic type may not develop symptoms until middle age. People with the familial type may develop symptoms during childhood.
Symptoms may not begin immediately after exposure to sunlight, so people may not realize that sun exposure is causing the symptoms.
People with porphyria cutanea tarda experience chronic, recurring blisters of various sizes on sun-exposed areas such as the arms, face, and especially the backs of the hands. Crusting and scarring follow the blisters and take a long time to heal. The skin, especially on the hands, is fragile and sensitive to minor injury.
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Sometimes sun exposure causes swelling, itching, or redness. Hair growth on the face and other sun-exposed areas may increase. Sometimes areas of dark or light patches of skin develop.
Diagnosis of Porphyria Cutanea Tarda
Testing blood, urine, and stool for porphyrins
To diagnose porphyria cutanea tarda, doctors test blood, urine, and stool for unusually high levels of porphyrins. The specific porphyrins that are increased provide a pattern that allows doctors to distinguish porphyria cutanea tarda from other porphyrias.
Doctors usually do tests to determine the factor that precipitated the development of porphyria cutanea tarda and to see whether there is too much iron in the liver. If people are not already known to have hepatitis C or HIV infection, doctors do tests for those disorders.
Treatment of Porphyria Cutanea Tarda
Removal of blood (phlebotomy)
Increase porphyrin excretion in the urine
Treatment and cure of hepatitis C infection, if present
For people with hepatitis C virus infection or HIV infection, treating these disorders with antiviral medication helps the porphyria.
Phlebotomy
A procedure called phlebotomy, in which a pint (almost half a liter) of blood is removed, is the most widely recommended treatment. Doctors typically do 6 to 10 sessions of phlebotomy, with sessions 2 to 4 weeks apart. With phlebotomy, the excess iron is gradually removed, the activity of uroporphyrinogen decarboxylase in the liver returns toward normal, and porphyrin levels in the liver and blood fall gradually. The skin symptoms resolve.
Phlebotomy sessions are stopped when people become slightly iron deficient (or almost so). Anemia may develop if too many phlebotomy sessions are done or if sessions are done too frequently.
For people taking estrogen, doctors stop the estrogen therapy (because it is a precipitating factor of the porphyria) until phlebotomy has been completed and porphyrin levels are normal.
Medications to increase porphyrin excretion
Medications to treat chronic hepatitis C
Several medications and combinations of medications that are highly effective for the treatment and cure of chronic hepatitis C, called direct-acting antiviral medications, are now in widespread use. Use of these medications, along with decreasing alcohol use and quitting smoking, can usually treat and cure both the hepatitis and porphyria cutanea tarda.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
American Porphyria Foundation: Aims to educate and support patients and families affected by porphyrias
The United Porphyrias Association: Provides education and support to patients and their families; provides reliable information to health-care providers; fosters and supports clinical research to improve diagnosis and management of the porphyrias
