MDNews - Minnesota

Case of the Month with +++++++++++++++++++ +++ + +++ + +++++++++++++++++++ DIAGNOSTICS ❯ By Charles E. Crutchfield III, MD Crutchfield Dermatology A 31 YEAR-OLD MAN presented with a four-month history of pruritic vesicles and crusts on his forearms, scalp, posterior neck and backside. He is otherwise healthy and on no medications. What is your diagnosis? Diagnosis: Dermatitis Herpetiformis Dermatitis herpetiformis (DH) — also known as Duhring's disease — is an intensely pruritic auto-immune vesiculobullous disorder and commonly causes lesions on forearms, scalp, posterior neck and backside. The blistering reaction is mediated by IgA autoantibodies. The condition is so intensely pruritic that most patients present with ulcers and crusts, rather than vesiculobullous from excoriation. DH often affects young adults, and 65 percent of patients are male. There is an association with human leukocyte antigens DQ2 DQ8. DH is associated with celiac disease, and 80 percent of patients with DH also have a gluten sensitivity/enteropathy — the most common form of celiac disease. A diagnostic biopsy will show dermal microabsesses rich in neutrophils. This is a relatively rare condition, and if the examiner does not consider it in the differential, it may be missed. Treatment Address any potential cutaneous infections upon presentation. In my experience, Dapsone is the treatment of choice. Start with 100 mg/day, but some patients may require up to 300 mg/day. I have one patient who successfully manages the condition with only 25 mg/day. Every patient is unique, and finding the best dosage requires titration. Most patients do well in the 100-200 mg/ day range. If using Dapsone, make sure the patient is not G6PD deficient, or you may get a phone call from the ER (as I did on the first and only patient I did not check), notifying you that your patient is blue and not feeling well. For more information, contact Charles E. Crutchfield III, MD, at Crutchfield Dermatology or visit CrutchfieldDermatology.com ■ 1 4 | Minnesota MD NEWS ■ M D N E W S . CO M

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