From the Guidelines
The patient's elevated ferritin level of 862 μg/L along with a pruritic rash suggests possible hemochromatosis or another iron overload disorder, and I strongly recommend immediate evaluation by a hematologist or dermatologist to prevent long-term complications such as liver disease, arthritis, and cardiac arrhythmias. The first step in testing for haemochromatosis is the assessment of serum iron parameters, which should include transferrin saturation and serum ferritin 1. Initial management should include phlebotomy therapy to reduce iron levels, starting with removal of one unit of blood (approximately 500 mL) every 1-2 weeks until ferritin levels decrease to 50-100 μg/L. For symptomatic relief of the pruritus, use a medium-potency topical corticosteroid such as triamcinolone 0.1% cream applied twice daily to affected areas for 7-10 days, along with an oral antihistamine like cetirizine 10 mg daily. Some key points to consider in the management of this patient include:
- Avoiding alcohol and iron supplements, and limiting consumption of red meat and vitamin C with meals as these increase iron absorption 1
- Additional testing should include transferrin saturation, complete blood count, liver function tests, and genetic testing for HFE gene mutations (C282Y and H63D) 1
- Regular monitoring of ferritin levels every 2-3 months is essential during treatment to prevent iron overload and its associated complications 1
- Consideration of other potential causes of pruritus, such as liver disease, neuropathy, or malignancy, and referral to relevant specialists as needed 1
From the Research
Pruritic Rash with Elevated Ferritin Levels
- A pruritic rash with ferritin levels of 862 ng/mL may be associated with hyperferritinemia, which can be caused by various conditions, including iron overload, metabolic syndrome, and inflammatory diseases 2, 3.
- Studies have shown that phlebotomy can be an effective treatment for pruritus associated with hyperferritinemia, leading to complete resolution of symptoms in some cases 2, 3.
- Hyperferritinemia can be a marker for underlying severe conditions, such as infections, cardiovascular diseases, endocrinological disorders, autoimmune diseases, and malignancies 4.
- The clinical interpretation of ferritin levels and appropriate diagnostic workup are essential in identifying and managing these conditions to reduce morbidity and mortality 4, 5.
- Ferritin measurement is a common laboratory test in dermatology, and changes in ferritin levels can be nonspecific, requiring correlation with specific clinical findings and risk factors 6.
Possible Causes of Hyperferritinemia
- Iron overload due to hereditary hemochromatosis or secondary iron overload from conditions such as alcohol use disorder or non-alcoholic fatty liver disease 2.
- Metabolic syndrome, which can lead to dysmetabolic hyperferritinemia 3.
- Inflammatory diseases, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis 4.
- Infections, cardiovascular diseases, endocrinological disorders, autoimmune diseases, and malignancies 4, 5.
Diagnostic Approach
- Measurement of serum ferritin levels and transferrin saturation to assess iron status 2, 3.
- Genetic testing to rule out hereditary hemochromatosis 2.
- Imaging studies, such as magnetic resonance imaging, to confirm hepatic iron overload 3.
- Diagnostic workup to identify underlying conditions, including laboratory tests and clinical evaluations 4, 5.