Biomedical Sciences, Biomed Biopharm Res., 2021; 18(1):62-67

doi: 10.19277/bbr.18.1.250; download pdf version [+] here  

Herpetiform dermatitis (Clinical case)

Bruno Sousa ^1,2,3, Nelson Tavares ^1,2*

¹School of Sciences and Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal; ²CBIOS – Universidade Lusófona's Research Center for Biosciences and Health Technologies, Lisboa, Portugal; ³Health Service of Autonomous Region of Madeira, Madeira, Portugal

* corresponding author: nelson.tavares@ulusofona.pt

A 44-year-old female teacher was referred to the Nutrition Consultation for Dermatology for a gluten-free diet. She had experienced a cluster of red and intensely itchy blisters at the cutaneous level for approximately six months. After a study by Dermatology, a herpetiform dermatitis was diagnosed. While waiting for the Nutrition Consultation, she removed the gluten from her diet and saw improvements in symptoms. Awaiting Gastroenterology Consultation.

Keywords: Duhring Brocq disease; dermatitis; herpetiformis; gluten-free diet

Received: 03/12/2020; Accepted: 26/02/2021

Anthropometric assessment

Weight: 59.9 kg

Height: 164 cm

BMI: 22.3 kg/m²

Usual weight: 62 kg

Body composition assessment (TANITA TBF 300^®)

Body fat: 28.9%

Fat mass: 17.3 kg

Non-fat mass: 42.6 kg

Total body water: 31.2 kg

Analytical Parameters

Hematology

Red blood cells: 4.54 x10¹²/L (4.50 – 6.40)

Hemoglobin: 14.2 g/dL (13.0-16.5)

Hematocrit: 40.9 % (39.8-52.0)

White blood cells: 5.64 x10⁹ /L (4.0 – 10.0)

Neutrophils: 4.25 x10⁹ /L (1.5– 8.0)

Eosinophils: 0.1 x10⁹ /L (<0.5)

Basophils: 0.1 x10⁹ /L (<0.3)

Lymphocytes: 1.63 x10⁹ /L (0.8-4.0)

Monocytes: 0.4 x10⁹ /L (<1.2)

Sedimentation speed: 7 mm/h (up to 20)

Biochemistry

Glucose: 97 mg/dL (67 - 110)

Hemoglobin HbA1c assay: 5.2% (3.8-5.8)

Urea: 19 mg/dL (10 - 55)

Creatinine: 0.7 mg/dL (0.6-1.4)

Uric acid: 4.6 mg/dl (2.4-5.7)

Glutamic-oxalacetic transamines: 16 U/L (10 - 35)

Glutamic-pyruvic transamines: 12 U/L (10 - 44)

Glutamyltransferase Range: 10 U/L (5 - 38)

C-reactive protein: negative

Total Cholesterol: 184 mg/dl (100-190)

HDL cholesterol: 54 mg/dl (> 45)

LDL cholesterol: 115 mg/dl (35-110)

Triglycerides: 75 mg/dl (5-184)

Calcium: 9. 6 mg/dl (8.4-10.4)

Phosphorus: 3.2 mg/dl (2.4-4.0)

Magnesium: 1.9 mg/dl (1.6 - 2.6)

Total vitamin D: 48.0 ng/ml (> 20)

Folic acid: 11.54 ng/ml (3-17)

Vitamin B12: 294.10 pg/ml (200-950)

Ferritin: 121.5 ng/ml (9-120)

TSH - Thyrostimulating Hormone: 1.48 UI/L (0.5-6)

T4 - Tetraiodothyronine: 11.32 μg/dl (4-13)

Gliadin - Ac. IgA: 1.4 AU/ml (<10)

Gliadin - Ac. IgG: <0.6 AU/ml (<10)

Tissue Transglutaminase - Ac. IgA: 0.3 AU/ ml (<10)

Tissue Transglutaminase - Ac. IgG: <0.4 AUml (<10)

S. cerevisae- ASCA, Ac.IgG: 2 U/ml (<10)

Calprotectin: 37 mg/kg (up to 50)

Clinical evaluation

Personal background

- Allergic rhinitis

- Asthma

Complementary diagnostic tests

Biopsy of skin lesion on the scalp:

The presence of neutrophils, some eosinophils, and nuclear debris along the dermoepidermal junction, are compatible with the diagnosis of Dermatitis herpetiformis.

Intestinal transit: regular

Eating habits

Wake up at 7 am

Breakfast: 7:30 am

1 cup of unsweetened coffee + 1 gluten-free bread with cheese

Morning snack: 10 am

1 piece of fruit

Lunch: 1 pm

Dish: ¼ of rice / potato dish + meat or fish (120 g) + varied vegetables (150 g) seasoned with olive oil

Dessert: 1 piece of fruit

Afternoon snack: 4:30 pm

1 cup of unsweetened coffee + 1 gluten-free bread with cheese

Dinner: 8 pm

Dish: ¼ of rice / potato dish + meat or fish (120 g) + varied vegetables (150 g) seasoned with olive oil

Go to bed at 10:30 pm

Water / tea consumption: about 1.5 liters of water per day

Environment, behavior and social

She lives with her husband and two teenage children. In view of the pandemic situation, it is limited to her family and professional life, with no social activities. She states that the current situation has also conditioned her physical exercise routine.

Questions

1. What is herpetiform dermatitis?
2. Do patients with herpetiform dermatitis have any enteropathy?
3. Is herpetiform dermatitis not related to herpesvirus?
4. What is the appropriate treatment for this pathology in addition to the pharmacological approach?
5. What are the consequences of adherence to a gluten-free diet by patients with herpetiform dermatitis?

Authors Contributions Statement

The contribution to the preparation of this Case Study was identical for both authors.

Acknowledgements

The authors wish to express their thanks to the patient who allowed the elaboration of the case study.

Conflict of Interests

The authors declare there are no financial and personal relationships that could present a potential conflict of interests.

Answers

1. Herpetiform dermatitis (HD), or Duhring Brocq disease, is a chronic, benign inflammatory skin disease, considered the specific cutaneous manifestation of celiac disease (CD). It is characterized: (i) symmetrical polymorphic lesions involving typical areas, such as the extensor aspects of the limbs and sacral region, (ii) a predominant neutrophilic infiltrate in the dermal papillae in histopathology, (iii) granular IgA deposits along the dermoepidermal junction, (iv) an invariable association with celiac disease, and (v) a lifelong response to a gluten-free diet.
2. Small bowel involvement is generally asymptomatic and only about 20% of HD people have gastrointestinal symptoms of celiac disease (CD).

Intestinal biopsy in HD shows alterations identical to those of CD, but lighter lesions with different distribution predominate, such as the existence of a subtle infiltrative pattern with partial atrophy or without villous atrophy, and at least 80% of individuals with HD have some degree of histological changes in the small intestine.

3. The term herpetiform describes the way the blisters are grouped (similar to the rash caused by some herpesviruses), but there is no relationship between the diseases.
4. After diagnosis, a strict gluten-free diet (GFD) must be implemented, which is considered the basis of HD treatment and must be maintained for life. However, with the return to a normal diet, the disease may recur.
5. Skin lesions are reversed, but recovery can be slow and may take up to two years after beginning a GFD to completely disappear. A GFD reverses gastrointestinal symptoms more quickly.

The early institution of a GFD is mandatory, since, in addition to ensuring a good clinical evolution of HD and CD, it prevents future complications, namely small intestine lymphoma.

References

1. Reunala, T., Salmi, T. T., Hervonen, K., Kaukinen, K., & Collin, P. (2018).Dermatitis Herpetiformis: A Common Extraintestinal Manifestation of Coeliac Disease. Nutrients, 10(5), 602. https://doi.org/10.3390/nu100506022.
2. Caproni, M., Antiga, E., Melani, L., Fabbri, P., & Italian Group for Cutaneous Immunopathology (2009). Guidelines for the diagnosis and treatment of dermatitis herpetiformis. Journal of the European Academy of Dermatology and Venereology : JEADV,23(6), 633–638. https://doi.org/10.1111/j.1468-3083.2009.03188.x2
3. Antiga, E., Maglie, R., Quintarelli, L., Verdelli, A., Bonciani, D., Bonciolini, V., & Caproni, M. (2019).Dermatitis Herpetiformis: Novel Perspectives. Frontiers in immunology, 10, 1290. https://doi.org/10.3389/fimmu.2019.01290