Document Type : Images in clinical practice
Author
Department of Dermatology, Al-Ramadi Teaching Hospital, Anbar Health Directorate, Anbar, Iraq
Abstract
A19-years-old male patient presented to the dermatology clinic complaining of severe itching with excoriations of the skin for 7 months ago. On examination, there were multiple crusted erosions, some vesicles, and scars of previous attacks on both elbows (Panel A), knees, thigh, upper back, forehead, scalp, and sides of the face. Punch biopsy was taken that revealed neutrophilic microabscess at the tip of the dermal papillae with subepidermal separation with mainly neutrophils infiltrates (Panel B-X10 and C-X40). Immunofluorescence studies and enzymes assays for dermatitis herpetiformis (DH) and celiac disease are not available in our locality. Accordingly, DH was diagnosed and treated with Dapsone 100 mg/day after no remarkable changes on hematological investigations. DH is a vesicobullous disease manifested as severely pruritic and grouped excoriations of the skin. The lesions are symmetrically distributed on the extensor surfaces of the elbows, knees, scalp, back, and buttocks. There is usually an associated gluten-sensitive enteropathy. Histopathologically, subepidermal separation with neutrophilic microabscess at the tips of dermal papillae are seen. Immunofluorescence shows granular IgA deposits at the dermo-epidermal junction that differentiate it from a linear IgA bullous disease which resembles it clinically. Dapsone is the drug of choice with a gluten-free diet. At three-months follow-up, the patient was put on Dapsone 75 mg/day and advise him to attend regular follow-ups every three months in order to reduce the dose of Dapsone to a minimum dose to control his condition.
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