Name That Rash

The rash pictured below (various patients) is intensely itchy, blistering, and symmetric. It is commonly misdiagnosed as eczema. What is it? How do we treat it? 

Source: DermNet

Dermatitis herpetiformis (DH) is a cutaneous form of gluten sensitivity that predominantly affects adults aged 30-40yo; it is rare in children. Interestingly, while over 90% of patients with DH exhibit small bowel biopsy findings consistent with celiac disease, only the minority of DH patients have clinically significant GI symptoms. 

The classic finding in DH is intensely pruritic papules/vesicles that appear in grouped (“herpetiform”) arrangements. Patients often scratch the lesions to the point that they may present with only erosions and excoriations. The eruption is symmetrically distributed and most often appears on the extensor surfaces of the arms and legs scalp, and buttocks. Because of its similarities with eczema and bullous disorders, diagnosis often requires biopsy (showing IgA deposits). 

A gluten-free diet is the cornerstone of therapy. Oral dapsone provides rapid relief of skin symptoms. 

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