Dermatitis herpetiformis – diagnostic difficulties based on the presentation of own cases

Introduction. Dermatitis herpetiformis (Duhring disease) is an autoimmune blistering subepidermal dermatosis characterized by pruritic polymorphic skin eruption accompanied by a clinically asymptomatic gluten-sensitive enteropathy. The etiopathogenesis of the disease is associated with the presence of antibodies against tissue and epidermal transglutaminase. Diagnosis is based on direct immunopathological examination in which granular IgA deposits on the top of dermal papillae are detected. Sulfones are effective in the therapy of skin changes.

Objective. The aim of the study is to present difficulties in evaluation of clinical picture, diagnosis and treatment, and monitoring the safety of the therapy in Duhring disease on the basis of three own cases.

Case report. Case 1. 37-year-old patient. Itchy skin lesions occurred in mid-2012 and have been treated until now with antihistamines and local corticosteroids without improvement. The diagnosis of dermatitis herpetiformis was established on the basis of direct immunopathology test. Treated with gluten-free diet and dapsone 100 mg/day with improvement. Case 2. 62-year-old patient, in whom the first itchy eruption appeared in October 2012. Treated with antihistamines and topical corticosteroids without improvement. In laboratory examinations elevated level of IgE and triglycerides was found. Histopathological and immunological examinations confirmed the diagnosis of dermatitis herpetiformis. Treated with gluten-free diet and dapsone 150 mg/day with improvement. Case 3. 58-year-old patient. The first changes of typical morphology appeared about 2 years ago. The patient was treated with antihistamines and corticosteroids without improvement. Laboratory tests confirmed the diagnosis of Duhring disease. The introduction of gluten-free diet and dapsone 100 mg/day caused regression of skin changes.

Conclusions. Our cases, treated for a long time as eczematous changes, despite the lack of improvement after treatment with antihistamines and local corticosteroids, illustrate the diagnostic difficulties in dermatitis herpetiformis. It should be emphasized that polymorphic changes are not always visible in all stages of the disease, which can cause difficulties in the diagnosis.