Guidelines for the diagnosis and treatment of dermatitis herpetiformis

Abstract

Case description: A 67 years old man presented to the clinic complaining of an itchy blistering skin rash over elbows, knees and buttocks for the past 2 months that is not responding to antihistamines. Itching has no diurnal variation. Patient has no chronic comorbidities a nd is not on regular medications. On examination, symmetrical vesicular lesions with erythema, crusting and itch marks are seen over both elbows, knees and back with-ve Nicolsky's sign. General examination reveals pallor, patient BMI 17.5, abdominal diste ntion, and peripheral neuropathy. Investigations showed microcytic hypochromic anemia with HGB 9.8 mg/dl, MCV 68, HCT 29.8, WBCs and platelets are normal. K 3.1 mg/dl, Na 135 meq/dl , Ca 8.5mg/dl, albumin 3 g/dl. Skin biopsy and direct immunofluorescence of t he skin around the lesions was taken that was diagnosed as dermatitis herpetiformis. Endoscopy was done and it confirmed the diagnosis of celiac disease.Treatment: Patient was advised to follow a gluten free diet plan and dapsone was started at a dose of 1 00 mg/day. Patient rash resolved gradually over a period of 3 weeks.

Dermatitis herpetiformis: celiac disease of the skin. Report of two cases

“…Serological tests, especially anti-tissue transglutaminase IgA antibodies and antiendomysium, are sensitive and specific tools for initial detection of gluten-sensitive diseases as well as for dermatitis herpetiformis [13].…”

A Case of a Rare Skin Manifestation of Celiac Disease

“…Also, screening for thyroid disorders and diabetes should be done. Screening for CD among symptomatic first degree relatives of patients with DH is indicated 12 .…”

“…Although CD is more predominant among females with a female to male ratio of about 2:1 to 4:1, yet DH is more common among males with a ratio of 1.5:1 to 2:1 [10][11] . Dermatitis herpetiformis usually presents in the third decade, although individuals of any age can be affected 12 . Direct immunofluorescence (DIF) of uninvolved skin remains the gold standard for establishing dermatitis herpetiformis diagnosis 13-14. Although most patients with DH have the histologic changes suggestive of gluten hypersensitivity, only 10-15% have clinical symptoms of CD…”

Application of dapsone 5% gel in a patient with dermatitis herpetiformis

“…4 Adverse effects of dapsone are generally dose-dependent and are more commonly observed in patients with comorbid conditions such as anemia and cardiopulmonary disease. 3 Other rare complications include agranulocytosis early on, as well as a systemic drug hypersensitivity syndrome, a serious complication that requires medication withdrawal and systemic corticosteroid administration. 5 Regular follow-up visits and routine laboratory monitoring of blood counts are needed for patients receiving treatment with oral dapsone, especially during the first 3 months.…”

“…The main side effects associated with oral dapsone may be classified as toxic/pharmacologic or idiosyncratic/allergic; these range from hemolytic anemia, the most common complication within 2 weeks after starting therapy, to nephritis and renal failure, precluding the need for strict monitoring of renal function tests. 3 Hemolytic anemia occurs in virtually every patient on oral therapy and may even occur in breastfed infants since dapsone is secreted in breast milk. A notable complication, especially in patients with glucose-6-phophate dehydrogenase (G6PD) deficiency, is hemolysis and methemoglobinemia due to oxidative stress from the hydroxylamine metabolite.…”