Review Question - QID 106324

Given the patient's history of celiac disease, the papulovesicular rash is most likely dermatitis herpetiformis (DH). This is best treated with dapsone and a gluten-free diet.

DH is a relatively uncommon sequelae of celiac disease. It presents with erythematous vesicles/bullae and papules that occur symmetrically and bilaterally in a grouped arrangement (hence the "herpetiform" appearance). Given that the rash is intensely puritic, however, excoriations and erosions are commonly seen on presentation. These lesions commonly appear on the buttocks, neck/upper back, and extensor surfaces.

As Lovett notes, DH is best thought of as a complication of untreated celiac disease. The pathologic changes of the small intestine associated with celiac disease are found in nearly 100 percent of patients who present with DH.

Cardones et al. discuss that the first-line treatment for DH is dapsone and elimination of gluten from the diet. During dapsone therapy, careful laboratory monitoring is necessary, as the drug is associated with a variety of adverse effects (see Illustration B).

Figure A shows the characteristic DH rash.
Illustration A shows the DH rash distribution.
Illustration B is a table listing the adverse effects of dapsone.

Incorrect answers:
Answer 1: Permethrin cream is appropriate treatment for scabies.
Answer 2: Topical antibiotics would be appropriate for cellulitis.
Answer 3: Acyclovir would be appropriate for a herpes skin infection. Although dermatitis herpetiformis resembles herpes (vesicles/papules on an erythematous base), the location of the rash and the history of celiac disease make herpes unlikely in this scenario.
Answer 4: Topical steroids are used in treating atopic dermatitis.