DERMATITIS HERPETIFORMIS

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Checklist for Dermatitis Herpetiformis

Rating	Nutritional Supplements	Herbs
	Selenium Vitamin E
	Betaine HCl Folic acid (if deficient) Iron (if deficient) Multiple vitamin-mineral PABA Vitamin B12 (if deficient) Vitamin B3 (nicotinamide, when combined with tetracycline) Zinc (if deficient)
Reliable and relatively consistent scientific data showing a substantial health benefit. Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit. An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of dermatitis herpetiformis? DH is characterized by intensely itchy hives or blister-like patches of skin located primarily on elbows, knees, and buttocks, although other sites may be involved. A burning or stinging sensation may accompany the itching.

How is it treated? The conventional treatment for DH is strict adherence to a gluten-free diet. Medications such as dapsone or sulfapyridine are prescribed to treat the rash.

Dietary changes that may be helpful: The cause of DH is mainly an allergic reaction (called hypersensitivity) to foods (wheat and other grains) containing a protein called gluten. People with DH are usually found to have abnormalities of the intestinal lining identical to that of celiac disease (also called gluten-sensitive enteropathy or celiac sprue),² a serious intestinal disorder also due to gluten sensitivity. Unlike celiac disease however, gastrointestinal symptoms may be mild or absent in DH.^{3 4 5 6}

Strict adherence to a lifelong gluten-free diet (GFD) can eliminate symptoms of DH and the intestinal abnormalities, as well as reduce or eliminate the need for medication in most people. However, an average of 8 to 12 months of dietary restriction may be necessary before symptoms resolve.^{7 8 9 10 11 12 13 14 15}

An increased incidence of lymphoma (cancer of the lymph tissue),^{16 17 18} and certain autoimmune and connective tissue disorders^{19 20} have also been reported in DH. Preliminary studies suggest a strict GFD of at least five years’ duration may reduce the increased risk of developing lymphoma in DH.^{21 22 23}

Not all people with DH improve on a GFD and/or medication. Preliminary studies indicate sensitivity to other dietary proteins may be involved.^{24 25 26} Some practitioners would recommend an elimination diet and/or allergy testing to check for other food sensitivities.

A milk-free diet may improve symptoms of dermatitis herpetiformis, according to uncontrolled preliminary reports. In these reports, intake of milk products intensified symptoms of DH in two patients despite adherence to a gluten-free diet. The combination of a milk-free and gluten-free diet was effective, however.^{27 28}

Nutritional supplements that may be helpful: People with DH frequently have mild malabsorption (difficulty absorbing certain nutrients) associated with low stomach acid (hypochlorhydria) and inflammation of the stomach lining (atrophic gastritis).²⁹ Mild malabsorption may result in anemia³⁰ and nutritional deficiencies of iron, folic acid,^{31 32} vitamin B12,^{33 34} and zinc.^{35 36 37} More severe malabsorption may result in loss of bone mass.³⁸ Additional subtle deficiencies of vitamins and minerals are possible, but have not been investigated. Therefore, some doctors recommend people with DH have their nutritional status checked regularly with laboratory studies. These doctors may also recommend multivitamin-mineral supplements and, to correct the low stomach acid, supplemental betaine HCl (a source of hydrochloric acid).

Para-aminobenzoic acid (PABA) in high amounts (9–24 grams per day) has been reported to reduce or eliminate the skin lesions of DH in one preliminary, clinical trial.³⁹ With continued administration, people with DH remained symptom-free for as long as 30 months. Since supplementation with such large amounts of PABA has the potential to cause side effects, these amounts should be used only with medical supervision.

A deficiency in the selenium-containing antioxidant enzyme known as glutathione peroxidase has been reported in DH.^{40 41} Preliminary⁴² and double-blind⁴³ trials suggest that supplementation with 10 IU of vitamin E and 200 mcg of selenium per day for six to eight weeks corrected this deficiency but did not lead to symptom improvement in the double-blind trial.

There is preliminary evidence that, when drug therapy with dapsone is not tolerated, people with DH may respond to a combination of the antibiotic, tetracycline, and nicotinamide (a form of vitamin B3).^{44 45} However, this course of treatment should only be tried under the supervision of a physician.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

1. Gawkrodger DJ, Blackwell JN, Gilmour HM, et al. Dermatitis herpetiformis: diagnosis, diet and demography. Gut 1984;25:151–7.

2. Otley C, Hall RP. Dermatitis herpetiformis. Dermatol Clin 1990;8:759–69 [review].

3. Reunala T, Kosnai I, Karpati S, et al. Dermatitis herpetiformis: jejunal findings and skin response to gluten free diet. Arch Dis Child 1984;59:517–22.

4. Hall RP. Dietary management of dermatitis herpetiformis. Arch Dermatol 1987;123:1378a–80a.

5. Ferguson A, Blackwell JN, Barnetson RS. Effects of additional dietary gluten on the small-intestinal mucosa of volunteers and of patients with dermatitis herpetiformis. Scand J Gastroenterol 1987;22:543–9.

6. Yancy KB, Lawley TJ. “Immunologically Mediated Skin Diseases.” Harrison’s Online. 1999. http://www.harrisonsonline.com/hill-bin/Chapters.cgi (Jan 10, 2000).

7. Fry L. Dermatitis herpetiformis. Baillieres Clin Gastroenterol 1995;9:371–93 [review].

8. Reunala T, Kosnai I, Karpati S, et al. Dermatitis herpetiformis: jejunal findings and skin response to gluten free diet. Arch Dis Child 1984;59:517–22.

9. Garioch JJ, Lewis HM, Sargent SA, et al. 25 years’ experience of a gluten-free diet in the treatment of dermatitis herpetiformis. Br J Dermatol 1994;131:541–5.

10. Chorzelski TP, Rosinska D, Beutner E, et al. Aggressive gluten challenge of dermatitis herpetiformis cases converts them from seronegative to seropositive for IgA-class endomysial antibodies. J Am Acad Dermatol 1988;18:672–8.

11. Hall RP. Dietary management of dermatitis herpetiformis. Arch Dermatol 1987;123:1378a–80a.

12. Kosnai I, Karpati S, Savilahti E, et al. Gluten challenge in children with dermatitis herpetiformis: a clinical, morphological and immunohistological study. Gut 1986;27:1464–70.

13. Ermacora E, Prampolini L, Tribbia G, et al. Long-term follow-up of dermatitis herpetiformis in children. J Am Acad Dermatol 1986;15:24–30.

14. Frodin T, Gotthard R, Hed J, et al. Gluten-free diet for dermatitis herpetiformis: the long-term effect on cutaneous, immunological and jejunal manifestations. Acta Derm Venereol 1981;61:405–11.

15. Fry L, Leonard JN, Swain F, et al. Long term follow-up of dermatitis herpetiformis with and without dietary gluten withdrawal. Br J Dermatol 1982;107:631–40.

16. Collin P, Pukkala E, Reunala T. Malignancy and survival in dermatitis herpetiformis: a comparison with coeliac disease. Gut 1996;38:528–30.

17. Leonard JN, Tucker WF, Fry JS, et al. Increased incidence of malignancy in dermatitis herpetiformis. Br Med J (Clin Res Ed) 1983;286:16–8.

18. Reunala T, Helin H, Kuokkanen K, Hakala T. Lymphoma in dermatitis herpetiformis: report on four cases. Acta Derm Venereol 1982;62:343–6.

19. Reunala T, Collin P. Diseases associated with dermatitis herpetiformis. Br J Dermatol 1997;136:315–8.

20. Christensen OB, Hindsen M, Svensson A. Natural history of dermatitis herpetiformis in southern Sweden. Dermatologica 1986;173:271–7.

21. Lewis HM, Renaula TL, Garioch JJ, et al. Protective effect of gluten-free diet against development of lymphoma in dermatitis herpetiformis. Br J Dermatol 1996;135:363–7.

22. Collin P, Pukkala E, Reunala T. Malignancy and survival in dermatitis herpetiformis: a comparison with coeliac disease. Gut 1996;38:528–30.

23. Leonard JN, Tucker WF, Fry JS, et al. Increased incidence of malignancy in dermatitis herpetiformis. Br Med J (Clin Res Ed) 1983;286:16–8.

24. Kadunce DP, McMurry MP, Avots-Avotins A, et al. The effect of an elemental diet with and without gluten on disease activity in dermatitis herpetiformis. J Invest Dermatol 1991;97:175–82.

25. van der Meer JB, Zeedijk N, Poen H, van der Putte SC. Rapid improvement of dermatitis herpetiformis after elemental diet. Arch Dermatol Res 1981;271:455–9.

26. Zeedijk N, van der Meer JB, Poen H, van der Putte SC. Dermatitis herpetiformis: consequences of elemental diet. Acta Derm Venereol 1986;66:316–20.

27. Engquist A, Pock-Steen OC. Dermatitis herpetiformis and milk-free diet. Lancet 1971;2:438–9.

28. Pock-Steen OC, Niordson AM. Milk sensitivity in dermatitis herpetiformis. Br J Dermatol 1970;83:614–9.

29. Yancy KB, Lawley TJ. “Immunologically Mediated Skin Diseases.” Harrison’s Online. 1999. http://www.harrisonsonline.com/hill-bin/Chapters.cgi (Jan 10, 2000).

30. Kastrup W, Mobacken H, Stockbrugger R, et al. Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia. Acta Med Scand 1986;220:261–8.

31. Gawkrodger DJ, Ferguson A, Barnetson RS. Nutritional status in patients with dermatitis herpetiformis. Am J Clin Nutr 1988;48:355–60.

32. Hoffbrand AV, Douglas AP, Fry L, Stewart JS. Malabsorption of dietary folate (Pteroylpolyglutamates) in adult coeliac disease and dermatitis herpetiformis. Br Med J 1970;4:85–9.

33. Davies MG, Marks R, Nuki G. Dermatitis herpetiformis—a skin manifestation of a generalized disturbance in immunity. Q J Med 1978;47:221–48.

34. Kastrup W, Mobacken H, Stockbrugger R, et al. Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia. Acta Med Scand 1986;220:261–8.

35. Crofton RW, Glover SC, Ewen SW, et al. Zinc absorption in celiac disease and dermatitis herpetiformis: a test of small intestinal function. Am J Clin Nutr 1983;38:706–12.

36. Gawkrodger DJ, Ferguson A, Barnetson RS. Nutritional status in patients with dermatitis herpetiformis. Am J Clin Nutr 1988;48:355–60.

37. Hoffbrand AV, Douglas AP, Fry L, Stewart JS. Malabsorption of dietary folate (Pteroylpolyglutamates) in adult coeliac disease and dermatitis herpetiformis. Br Med J 1970;4:85–9.

38. Di Stefano M, Jorizzo RA, Veneto G, et al. Bone mass and metabolism in dermatitis herpetiformis. Dig Dis Sci 1999;44:2139–43.

39. Zarafonetis CJ, Johnwick EB, Kirkman LW, Curtis AC. Paraaminobenzoic acid in dermatitis herpetiformis. Arch Dermatol Syph 1951;63:115–32.

40. Juhlin L, Edqvist LE, Ekman LG, et al. Blood glutathione-peroxidase levels in skin diseases: effect of selenium and vitamin E treatment. Acta Derm Venereol 1982;62:211–4.

41. Ljunghall K, Juhlin L, Edqvist LE, Plantin LO. Selenium, glutathione-peroxidase and dermatitis herpetiformis. Acta Derm Venereol 1984;64:546–7.

42. Juhlin L, Edqvist LE, Ekman LG, et al. Blood glutathione-peroxidase levels in skin diseases: effect of selenium and vitamin E treatment. Acta Derm Venereol 1982;62:211–4.

43. Ljunghall K, Juhlin L, Edqvist LE, Plantin LO. Selenium, glutathione-peroxidase and dermatitis herpetiformis. Acta Derm Venereol 1984;64:546–7.

44. Shah SA, Ormerod AD. Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide. Clin Exp Dermatol 2000;25:204–5.

45. Zemtsov A, Neldner KH. Successful treatment of dermatitis herpetiformis with tetracycline and nicotinamide in a patient unable to tolerate dapsone. J Am Acad Dermatol 1993;28:505–6.

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