++
A young man with a past history of diarrhea and malabsorption carries a past diagnosis of gluten-induced enteropathy. Despite a gluten-free diet he continues to have a pruritic eruption on his shoulders, back, extremities and buttocks. (Figures 186-11 and 186-12). While the most likely diagnosis is dermatitis herpetiformis, a punch biopsy was performed to confirm this before starting the patient on oral dapsone.
++
++
++
The clinical eruption is characterized by severe itching, burning, or stinging in the characteristic extensor distribution. Herpetiform vesicles and urticarial plaques may be seen. Because of the intense pruritus, characteristic lesions may be excoriated beyond recognition (Figures 186-11 and 186-12).
++
Classically, the lesions (or excoriations) are seen in the extensor aspects of the extremities, shoulders (Figures 186-11), lower back, and buttocks (Figures 186-12).
++
If the patient has gluten-induced enteropathy, antigliadin and antiendomysial antibodies may be present. A blood test for antigliadin antibody is a sensitive test for gluten-induced enteropathy.
++
Diagnosis is confirmed by a punch biopsy. It is best to biopsy new crops of lesions. A standard histologic examination will show eosinophils and microabscesses of neutrophils in the dermal papillae and subepidermal vesicles. Direct immunofluorescence reveals deposits of IgA and complement within the dermal papillae.
++
Follow-up is needed to control the disease and monitor nutritional status.
++
Nutritional counseling is important for all patients with gluten-induced enteropathy. Persons with dermatitis herpetiformis and gluten-induced, enteropathy should not eat wheat and barley but can eat rice, oats and corn.
++
++