Based on the gastrointestinal issues, weight loss, and skin findings, the family physician suspected dermatitis herpetiformis and performed a punch biopsy of an intact vesicle. Because of the weight loss he also ordered a complete blood count, thyroid stimulating hormone blood test, chemistry panel, and an anti-gliadin antibody level. The biopsy results and positive anti-gliadin antibody results confirmed the physician’s suspicions for dermatitis herpetiformis and gluten-induced enteropathy.
Dermatitis herpetiformis is a chronic recurrent symmetric vesicular eruption that is usually associated with gluten-induced enteropathy. It most commonly occurs in the 20- to 40-year-old age group. Men are affected more often than women.
The disease is related to gluten and other diet-related antigens that cause the development of circulating immune complexes and their subsequent deposition in the skin. The term herpetiformis refers to the grouped vesicles that appear on extensor aspects of the extremities and trunk and is not a viral infection or related to the herpes viruses. The disease is characterized by the deposition of IgA along the tips of the dermal papillae. The majority of patients will also have blunting and flattening of jejunal villi, which leads to diarrhea even to the point of steatorrhea and malabsorption.
With a gluten-free diet, 80% of patients will show improvement in the skin lesions. The degree of benefit is dependent upon the strictness of the diet. A gluten-free diet may help the enteropathy and decrease the subsequent development of small bowel lymphoma. Dapsone at an initial dose of 100 to 200 mg daily with gradual reduction to a 25 to 50 mg maintenance level may be needed in addition to the gluten-free diet.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Hara, J. Other bullous diseases. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:799-806.
To learn more about The Color Atlas of Family Medicine, see:
• http://www.amazon.com/Color-Atlas-Family-Medicine/dp/0071474641
The Color Atlas of Family Medicine is also available as an app for mobile devices. See