Was a pleasure to read Dr. Kotze review article on Dermatitis Herpetiformis (DH) in Arq Gatroenterology v. 50 nº 3 - jul/set.2013. In dermatology, aside the description of Louis Duhring (1884), Brocq´s (1888) “polymorphic pruritic dermatitis” is frequently reminded. Therefore, Duhring-Brocq’s disease is used as a synonym for DH(11. Katz SI. Dermatitis Herpetiformis. In: Fitzpatrick TB, Eisen AZ, Woff K, Freedberg IM, Austen KF. Dermatology in General Medicine. 7th ed. New York: McGraw-Hill. 2010. p.500-4.).
Over a 3-year period (2010 to 2012) 14 (9 male, 5 female) new cases of DH was diagnosed at The Dermatology Service of Hospital de Clínicas de Curitiba. Lesions usually begin with itching or burning sensation and erythematous papules or urticarial plaques. Grouped vesicles with centrifugal growth, with serous or hemorrhagic contents and symmetrical distribution were typical. Exulcerated skin and crusts were also seen, followed by residual hypo or hyperpigmentation. Even though, all the 14 patients were referred to Gastroenterology, only 6 of them pursue the specialist evaluation. This group, were probably bothered by abdominal symptoms. Two of these patients had Celiac disease confirmed by the intestinal biopsy
The 14 patients had the typical deposition of IgA immunoglobulin in a granular pattern at the top of the dermal papilla in the basement membrane. Most of these patients (eight) had more than one direct immunofluorescence (DIF) examination to confirm this finding. The skin biopsy for H&E sections should come from a new, intact bulla, but for the DIF perilesional skin was ideal. Since it is well known that DIF deposits can only be irradicated through a gluten-free diet for several years(11. Katz SI. Dermatitis Herpetiformis. In: Fitzpatrick TB, Eisen AZ, Woff K, Freedberg IM, Austen KF. Dermatology in General Medicine. 7th ed. New York: McGraw-Hill. 2010. p.500-4., 22. Mendes FB, Hissa-Elian A, Abreu MAMM, Gonçalves VS. Review: dermatitis herpetiformis. An Bras Dermatol. 2013;88:594-9.), sampling and DIF technique may be a problem in our group. As reported in the literature, thyroid disease was seen in two cases and type I diabetes in one case.
Regardless the evidence that a gluten-free diet alone improve or even lead to complete remission of skin lesions in DH, only one patient followed the diet for more than 4 months. Dapsone was the first therapeutic option in all cases. Variable dosages, from 100 mg a week to 300 mg a day were necessary for successful control of the skin lesions. Tetracycline 2 g, together with nicotinamide 1.5 g a day was a second line option for three of our patients who did not tolerate Dapsone. Over this 3-year period, several patients were clinically suspected of having DH because they present pruritic lesions on extensor areas, they were not included in this evaluation, even though some of them had some improvement with DH treatment, demonstrating that the skin disease may be more frequent than we suspect.
RESPONSE TO DR. BRENNER
I appreciate the interest of Dr. Brenner regarding my revision of Dermatitis herpetiformis. Also, I think it is very importante Brazilian physicians’ reports about this disorder, showing the interaction between dermatologists and gastroenterologists. Soon my personal experience with this affection will be published in the Revista Española de Enfermedades Digestivas. This paper will demonstrate similar data and can estimulate other authors to report their findings.
Lorete Maria da Silva KOTZE* * Escola de Medicina da Pontifícia Universidade Católica do Paraná - PUCPR, Curitiba, PR, Brasil.
Escola de Medicina da Pontifícia Universidade Católica do Paraná - PUCPR, Curitiba, PR, Brasil.
1Katz SI. Dermatitis Herpetiformis. In: Fitzpatrick TB, Eisen AZ, Woff K, Freedberg IM, Austen KF. Dermatology in General Medicine. 7th ed. New York: McGraw-Hill. 2010. p.500-4.
2Mendes FB, Hissa-Elian A, Abreu MAMM, Gonçalves VS. Review: dermatitis herpetiformis. An Bras Dermatol. 2013;88:594-9.
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