Dermatitis Herpetiformis

Intensely pruritic, chronic, recurrent, papulovesicular disease.
Underlying gluten-sensitive enteropathy - may be asymptomatic.

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Symptoms

Pruritus - first & predominant symptom.
Symmetrical eruption of grouped erythematous papules and papulovesicles rapidly excoriated - intact vesicles are difficult to demonstrate.
Extensor aspects of limbs (elbows and knees), buttocks, natal cleft, shoulders, upper back, face and scalp.
Oral lesions are common but asymptomatic.
Provocation of lesions occurs with iodides.

Complications

Secondary infection and ulceration

Causes

Antigen: Gut epithelial antigen cross reacts with skin
Antibodies: IgA directed against gliadin and autoantigens like reticulin and endomysium C3, IgG, IgM may be seen

Prevention

Stick to a gluten free diet

Risk Factors

Onset usually between 20-55 Years.
Mainly males.
External factors: Gluten containing diet like wheat, barley, oats and rye.

How is it diagnosed?

Investigation

Histology of intact vesicles reveals neutrophilic microabscesses at the tips of dermal papillae.
Direct immunofluorescence on clinically normal skin (buttocks) - granular IgA deposits in dermal papillae.

How is it treated?

Strict gluten free diet
Dapsone 100-200 mg/day
Sulphapyridine 1.5 g/ day
Tetracycline with nicotinamide
Colchicine when the above drugs are contraindicated

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