Integrated clinical assessment

Dermatitis herpetiformis:
Follow Up Questions/Answers

Please can you present your clinical findings in this case?

o This 60-year-old gentleman presented with a 3-month history of a blistering itchy
rash on his extensor surfaces, associated with GI symptoms. He had fingerprick
marks from his blood glucose testing.
o A vesicular rash over his extensor surfaces which was now encrusted showing
previous excoriation.

Do you have a diagnosis?

o I suspect this is dermatitis herpetiformis.
o His GI symptoms can be explained by coeliac disease.
Tell me more about coeliac disease.
o Coeliac disease is an autoimmune condition characterised by hypersensitivity to
gluten products.
o Resulting in villous atrophy and malabsorption.
If you suspect somebody to have coeliac disease, how would you investigate them
further?
o Initially I would like to do:
• baseline blood tests
• full blood count (looking for any signs of anaemia with ferritin, B12 and
folate)
• baseline kidney function.
• liver function tests.
• tissue transglutamase (with immunoglobulins as well).
o I would also refer the patient for an upper GI endoscopy with biopsy.

The results come back, and they confirm coeliac disease. How would you manage this
patient further?
o I would want to refer the patient to a dietician, (to advise on gluten product
avoidance eg bread and pasta).
o I would also want to correct any underlying nutritional deficiencies,
o I could consider doing a repeat biopsy in 6-months’ time to confirm villous
regeneration.
You see the patient in 6 months’ time, but you notice that the rash has failed to improve.
Are you aware of any other therapies that could be tried?
o I would try Dapsone.
Integrated clinical assessment

Dermatitis herpetiformis:

Key Words and Phrases

Dermatitis herpetiformis produces an itchy rash which is symmetrical and usually

distributed over the extensor surfaces of the body such as the elbows, knee,
buttocks, scalp, upper back and at pressure points. It is very occasionally generalised.

It is a rash made up of vesicles that are raised with reddened background. The vesicles
maybe ruptured due to the extreme itchiness, which may leave encrusted lesions. The
diagnosis is made on clinical and histological appearances of the skin with a skin biopsy
showing the dermal papillae containing micro abscesses infiltrated with neutrophils,
eosinophils and fibrin.

Dermatitis herpetiformis is nearly always associated with a gluten sensitive enteropathy,

also known as coeliac disease. Gluten is contained in wheat, rye, barley and oats.
Exposure of the jejunal mucosa to gluten results in villous atrophy and mucosal flattering
in turn causing malabsorption.
A jejunal biopsy demonstrating this appearance is diagnostic. Blood tests may show an
anaemia caused by malabsorption. Folate deficiency is invariably present and may cause
a raised MCV. Vitamin B12 deficiency is rare but iron deficiency maybe present. A blood
film may show both microcytes and macrocytes.

A gluten free diet usually produces a rapid clinical and morphological improvement
with complete recovery of the jejunal mucosa.
Replacement haemetinics are also given initially.
With any skin condition it is vital to know the appropriate describing words. Using the
correct diagnostic description conveys to the examiner a confident candidate who is
aware of the correct diagnosis.
Station 5 is one of the most difficult stations and learning the correct terminology
will place you in a commanding position.

Use words such as:

• macule - a flat, circumscribed lesion, not raised above the skin
• papule - raised, circumscribed, firm lesion up to 1cm in size
• nodule - like papule, but larger, usually lying deeper in the skin
• weals - circumscribed elevations associated with itching and tingling
• vesicles - small well-defined collections of fluid
• bullae - large vesicles
• pustules - circumscribed elevations containing purulent fluid
• scales - dead tissue from horny layer which may be dry, in conditions like psoriasis,
or greasy
• crusts - this is dried exudate
• ulcers - excavations in the skin of irregular shape, when describing ulcers
remember they have a shape, edge, floor and base and secretions to describe