LAUSR

To the Editor: Second-generation direct-acting drugs (DAAs) have revolutionized the treatment of chronic hepatitis C. However, skin-related adverse effects (AEs) have not been properly described and result a common enigma for medical personnel. This is the first case of an eczematous drug eruption because of secondgeneration DAAs. A 52-year-old man with a medical history of chronic hepatitis C virus (HCV) infection was on sofosbuvir/ velpatasvir for a total of 12 weeks, with sustained virologic response. He progressively developed pruritic skin lesions since the fourth week of treatment. His general health and laboratory examinations were normal. He was not on any other medication, and he denied an allergic history, sun exposure, or similar episodes in the past. Physical examination revealed several xerotic plaques with superficial cracks and fissures over an erythematous base, with abundant fissuring, oozing, and crusting. Lateral forearms were mainly involved, with associated volume increase, but thighs, hands, and abdomen were also affected (Figure 1). No face or mucosal involvement was noted. Clinical features were consistent with an asteatotic-like eczematous drug eruption. Skin lesions were managed with topical corticosteroids and fully resolved after drug discontinuation. No recurrence was observed during the 12-month follow-up. In 2011, first-generation DAAs telaprevir and boceprevir replaced pegylated interferon (peg-IFN) plus ribavirin for the treatment of HCV genotype 1. PegIFN–free regimens have shown less cutaneous AEs than Peg-IFN–containing regimens.1 Minor cutaneous AEs included pruritus and diffuse rash [,50% body surface area (BSA)], skin peeling, and mucous membrane involvement without ulceration. Mayor cutaneous AEs included generalized rash (.50% BSA), rashes with vesicles, bullae and ulcerations, drug reaction with eosinophilia and with eosinophilia and systemic symptoms, Stevens–Johnson syndrome, erythema multiforme, and toxic epidermal necrolysis.1 This AEs can progress despite drug discontinuation.2 Since 2013, new second-generation DAAs have been included for the treatment of HCV infection, including NS3/4A protease inhibitors (glecaprevir, grazoprevir, paritaprevir, simeprevir, and voxilaprevir), NS5A inhibitors (daclatasvir, elbasvir, ledipasvir, ombitasvir, pibrentasvir, and velpatasvir), and NS5B polymerase inhibitors (sofosbuvir and dasabuvir). New DAAs have fewer AEs and improved efficacy, but it remains