Dermatitis herpetiformis is a cutaneous manifestation associated with gluten sensitivity. It produces a chronic eruption characterized by clusters of intensely pruritic vesicles, papules, and urticaria-like lesions. The cause is autoimmune. Diagnosis is by skin biopsy with direct immunofluorescence testing. Treatment is usually with dapsone or sulfapyridine and a gluten-free diet.
This disease usually manifests in patients 30 to 40 yr old (but may occur from age 2 to 90 yr) and is rare in blacks and Asians.
More than 90% of affected patients have a gluten-sensitive enteropathy, which is often asymptomatic. Dermatitis herpetiformis develops in 15 to 25% of patients with celiac sprue. Patients have a slightly higher incidence of other autoimmune disorders, including type 1 diabetes mellitus, sarcoidosis, SLE, and thyroid abnormalities. The incidence of enteropathy-associated T-cell lymphoma is also increased.
The term herpetiformis refers to the clustered appearance of the lesions rather than a relationship to herpesvirus.
Symptoms and Signs
Onset is usually gradual. Vesicles, papules, and urticaria-like lesions are usually distributed symmetrically on extensor aspects (elbows, knees, sacrum, buttocks, occiput). Vesicles and papules occur in about one third of patients. Itching and burning are severe, and scratching often obscures the primary lesions with eczematization of nearby skin, leading to an erroneous diagnosis of eczema. NSAIDs and iodides may worsen the rash.
Diagnosis is based on skin biopsy and direct immunofluorescence testing of a lesion and adjacent normal-appearing skin. Granular IgA deposition in the dermal papillary tips is invariably present and important for diagnosis. Patients should be evaluated for celiac sprue (see Malabsorption Syndromes: Celiac Disease).
Strict adherence to a gluten-free diet for a prolonged time (eg, 6 to 12 mo) controls the disease in some patients, obviating or reducing the need for drug therapy. When drugs are needed, dapsone generally results in remarkable improvement. Initial dosages of dapsone are 25 to 50 mg po once/day in adults and 0.5 mg/kg in children. Usually, this dose dramatically relieves symptoms, including itching, within 1 to 3 days; if it does, the dose is continued. If no improvement occurs, the dose can be increased every week, up to 300 mg/day. Most patients can be maintained on 50 to 150 mg/day, and some require as little as 25 mg/wk. After initial therapy and stabilization of the disease, the majority of patients can be maintained on a strict gluten-free diet. Although less effective, sulfapyridine may be used as an alternative for patients who cannot tolerate dapsone. Initial oral dosage is 500 mg bid, increasing by 1 g/day q 1 to 2 wk until disease is controlled. Maintenance dosage varies from 500 mg twice/wk to 1000 mg once/day. Colchicine is another treatment option. Treatment continues until lesions resolve.
In patients with G6PD deficiency, dapsone may cause severe hemolysis. Patients receiving dapsone or sulfapyridine should have a baseline CBC; CBC is then done for 4 wk, then every 2 to 3 wk for 8 wk, and every 12 to 16 wk thereafter. Hemolytic anemia and methemoglobinemia are the most frequently encountered adverse effects. CNS or liver toxicity is rare. If dapsone therapy causes considerable hemolysis, significant cardiopulmonary problems, or peripheral neuropathy, sulfapyridine may be used. Sulfapyridine usually does not induce significant hemolysis.
Last full review/revision September 2008 by Julie E. Russak, MD