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Dermatitis Herpetiformis, Dr. Kim Alexander Papp
------------------------

Dr. Papp is a consultant at St. Mary's, Grand River, and Listowel
Memorial Hospitals.  He is also President of Probity Medical Research
Inc.

The first mention of Dermatitis Herpetiformis (DH) in the literature
was in 1884 in Dhring.  The connection to wheat was made in Dreke,
Holland in 1941.  It is an uncommon, but not rare, disease that
affects males twice as often as females.  It is found in 10% of first
degree relatives.  There is a genetic association; 90% of DH patients
have HLA-B8 vs.  only 15% of the general population.  HLA-DRw4 and
HLA-DQw2 are also associated with some DH patients.

DH normally is found on elbows, knees, shoulders, buttocks, sacrum,
posterior scalp, and face.  While it is unusual, it can also show up
on the hands or inside the mouth.  It presents as clear blisters that
itch very badly.  [One patient described the itch "...like rolling in
poison ivy naked with a severe sunburn, then wrapping yourself in a
wool blanket filled with ants and fleas."<1>-ed]

The original diagnosis of DH was done by giving Dapsone, a leprosy
drug, and noting any improvement.  Today, the "gold standard" for
diagnosing DH is a skin biopsy with immunofluorescence.  (A plain skin
biopsy is not sufficient.)  Most DH patients also have villi damage in
the small intestine and lymphocyte infiltration of the intestinal
wall, and IgA/IgG antigliadin antibodies in the bloodstream.  However,
there is really no need to perform a small bowel biopsy or test for
blood serum antibodies; the skin biopsy with immunofluorescence
provides a definitive diagnosis.

Dr. Papp indicated that about half of his patients are diagnosed
after having their symptoms recognized and pointed out to them by
other DH patients.

DH is not an allergic reaction; a different mechanism is involved.  It
is caused by antibodies to the gluten found in wheat, rye, and barley.

The causes of DH flares include large quantities of iodides (some
iodine is needed in the diet), kelp, shellfish, non-steroidal
anti-inflammatory agents (such as aspirin), gluten, stress, and some
cleansers.

What else looks like DH?

  *  DH can be misdiagnosed as psoriasis, or the patient may have both
     conditions.

  *  Linear IgA disease--the immunofluorescence pattern is different,
     but it looks and feels the same as DH to the patient.

  *  Allergic contact reactions.

DH is treated by adherence to a gluten-free (GF) diet.  The skin
lesions can be treated with either a sulfone (Dapsone) or sulfonamide
(Sulfapyradine) drug.  In about 85% of the cases, at least a year on a
strict GF diet is needed before DH is resolved.  In rare cases DH
lesions clear up after only a few weeks on the GF diet.

Dapsone can have side effects, though these are not common.  It can
alter blood chemistry, causing anemia.  Those of Mediterranean or
African ancestry can have sudden red blood cell count drops [known as
G6PD Deficiency--Dr. Alexander].  Other complications include
tingling fingers and neurological problems.

Ideally, if the patient is on medication there would be monthly lab
tests to monitor the dosage and effect on the patient.  This almost
never happens.

The GF diet takes a long time to bring DH under control because it
requires time to clear the IgA and IgG from the blood.  So even if one
is on a GF diet and/or taking Dapsone, technically one has DH.  Like
an alcoholic, one always has the disease.

Dr. Papp concluded his presentation by answering a few questions from
the audience.


Q:  How soon after ingesting gluten or iodine will a flare occur?

A:  It varies tremendously.  With iodine, it usually takes several
    days of consumption before a flare occurs.


Q:  What effect does stress have on a DH patient?

A:  It intensifies any symptoms the patient is experiencing.


Q:  What effect does iodine on the skin have?

A:  It really has no effect; it doesn't penetrate enough.  Iodine must
    be consumed to cause a DH flare.


Q:  After several years on a GF diet with no flares, is iodine still a
    problem?

A:  No.