Practice Easily missed?

Dermatitis herpetiformis

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2557 (Published 16 April 2014) Cite this as: BMJ 2014;348:g2557
  1. Adam D Jakes, academic foundation doctor1,
  2. Stephen Bradley, general practitioner trainee1,
  3. Lynn Donlevy, general practitioner partner2
  1. 1Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
  2. 2Silsden Group Medical Practice, Keighley, UK
  1. Correspondence to: A D Jakes adam.jakes{at}hyms.ac.uk
  • Accepted 6 March 2014

A 28 year old woman presented with a raised, red and intensely itchy rash on the extensor surface of her elbows and buttocks, in groups of small blisters. There was no history of trauma, atopy, or recent illness. She had no gastrointestinal symptoms or change in bowel habit and had not lost weight. No major medical or surgical history was noted and she was not taking drugs on a regular basis. Owing to the appearance and location of the rash, together with pruritus, dermatitis herpetiformis was suspected.

What is dermatitis herpetiformis?

Dermatitis herpetiformis is an inflammatory cutaneous condition closely associated with gluten sensitive enteropathy, but the exact mechanism is unknown. It may be the first manifestation of coeliac disease, as at least 75% of patients with dermatitis herpetiformis have some degree of enteropathy, varying from flat mucosa to partial villous atrophy.1 Gastrointestinal and abdominal symptoms are, however, usually absent.2 Conversely, only 24% of patients with coeliac disease develop dermatitis herpetiformis.3 The disease usually presents in young people (ages 15-40 years), is slightly more common in men, and predominately affects white people.4 The disease follows a chronic-relapsing course.5 The characteristic pruritic papulovesicular rash is most often evident on the extensor surfaces of elbows (fig 1) and knees, proximal forearms, scalp, and buttocks.4 Deposition of IgA at the dermal-epidermal junction, following sensitisation by gluten of the gut mucosa, is implicated in the disease and usually holds the key to definitive diagnosis.6

Fig 1 Characteristic pruritic papulovesicular rash of dermatitis herpetiformis, …

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