Clinical features

Onset of skin symptoms may be sudden or gradual.

• patients usually present with an intensely pruritic, skin eruptions
  • pruritus is often the predominant symptom
    • intense itch of DH result in vigorous scratching and extensive excoriation which frequently destroys areas of vesicles/blisters and leaves behind erosions
  • lesions consist of small papules or vesicles, which are often grouped together on erythematous patches of skin - as those of the true herpes virus, hence the name 'herpetiformis.'
  • small blisters are rarely seen since they are rapidly excoriated, leaving raw papules.
• skin lesions are symmetrically distributed and characteristically seen on extensor surfaces of limbs (classically the knees and just below the elbows), scalp, scapula, and natal cleft sparing the mucosae (1,2).

Several atypical presentations of DH have been reported e.g. -

• purpuric lesions resembling petechiae on hands and feet
• leukocytoclastic vasculitis-like appearance
• palmo-plantar keratosis
• wheals of chronic urticaria
• lesions mimicking prurigo pigmentosa (3)

About 90% of patients with dermatitis herpetiformis will have a gluten enteropathy (1).

• only few are symptomatic. They may complain of :
  • fatigue
  • abdominal discomfort and bloating
  • diarrhoea or constipation
  • weight loss
  • pale stools that float on the surface of the toilet pan (1)

Reference:

• (1) Primary Care Dermatology Society (PCDS). Dermatitis herpetiformis (Accessed 20/03/2017)
• (2) Jakes AD, Bradley S, Donlevy L.Dermatitis herpetiformis. BMJ. 2014;348:g2557.
• (3) Antiga E, Caproni M.The diagnosis and treatment of dermatitis herpetiformis. Clin Cosmet Investig Dermatol. 2015;8:257-65.