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Dermatitis Herpetiformis

Clinical Case

Case 1

  • 35-year-old female
  • No past medical history
  • Family history notable for celiac disease
  • Presents for evaluation and management of new, intensely pruritic eruption on elbows, lower back, hips, buttocks, posterior thighs. Prior treatments with topical corticosteroid creams and systemic antihistamines were unsuccessful
  • Patient reports vague abdominal complaints, including bloating and intermittent diarrhea

Initial evaluation

  • Thin, healthy-appearing young female
  • Excoriated erythematous papules and plaques with scattered bullae and crusted erosions
  • No evidence of linear burrows or other stigmata of scabetic disease
  • Diagnosis: DH
  • Skin biopsies (H&E, direct immunofluorescence) are performed to confirm the diagnosis
  • Treatment options discussed; patient opts for treatment to limit progression of new lesions. Dapsone 25 mg is prescribed for the first week with plan to escalate to 100 mg daily dosing. Diet review and strict gluten avoidance are recommended, and the patient is referred to nutrition counseling
  • Pre-treatment lab work is ordered: complete blood count with differential, glucose-6-phosphate dehydrogenase levels. Thyroid stimulating hormone level and anti-thyroid peroxidase levels are also checked based on patient’s report of unexplained weight changes and cold intolerance
  • Patient is referred to gastroenterology clinic for evaluation of celiac disease, malabsorption syndrome, and also recommendations for screening for bowel lymphoma
  • Patient is referred to dental clinic for evaluation of dental enamel defects
  • Follow-up in 1 month

One-month follow-up evaluation

  • The patient reports that gluten avoidance did not impact her skin lesions nor pruritus, but that the skin lesions quickly resolved within a week of starting dapsone. The patient reports that there are far fewer new lesions. Her subsequent blood work remains normal, indicating that she is tolerating the medication. Based on the patient reports of ongoing appearance of few new lesions, the dapsone dose is escalated to 150 mg daily dose
  • Follow-up in 1 month

Follow-up evaluation

  • Patient reports significant clinical improvement (no new lesions)
  • Dapsone is continued at 150 mg daily dose for two more weeks with plan to taper slowly whilst continuing strict gluten avoidance