Case Presentation - Dermatology

By- Fatema Burhan Ravat

Identifying data & Chief complaint

20 yo, Male, XYZ

Davao city, Phillipines

CC- A previously healthy 20-year-old male consulted

at the outpatient clinic with multiple blistering skin
eruptions.
HPI
● His condition started five weeks prior to consult when he noted appearance of
pruritic, tense, erythematous vesicles and bullae on the face.
● He did not complain of fever, body malaise, abdominal pain, diarrhea or
steatorrhea.
● He self medicated with an over-the-counter cream (clobetasol propionate +
ketoconazole cream) that did not provide any relief.
● He later consulted a physician and was given ciprofloxacin 500mg tablet twice
a day for seven days.
● However, there were still persistence and spread of lesions to the abdomen,
upper back and lower extremities.
PMH
● The patient does not have any history of hypertension, diabetes or asthma
● He denies any previous hospitalizations
● Family history was negative for atopy and autoimmune diseases
● His usual diet was rice, noodles, fish, chicken and milk with cereal
● He is sexually active, uses protection

PHYSICAL EXAMINATION

Revealed multiple tense vesicles and bullae with areas of erosions and crusts
symmetrically located on the face, axillae, trunk, buttocks and lower extremities.
Mucosal and genital areas were free of lesions.
Nikolsky sign - Negative, Asboe-Hansen sign- Negative
Differential diagnoses
● Bullous Pemphigoid
● Dermatitis Herpetiformis
● Linear IgA Disease
● Atopic Dermatitis
● Papular urticaria
● Epidermolysis Bullosa
NG- Neutrophil granulocytes; EG- Eosinophil granulocytes; BMZ - Basement Membrane Zone
Diagnostic tests
● Hematologic examination revealed normal hemoglobin and leukocytosis of
13.39 x 10’/ul with neutrophilic predominance.
● Serum chemistry was within normal range.
● Glucose-6-phosphate dehydrogenase (G6PD) test was within normal limits.
● Chest X-ray and stool exam were unremarkable as well.
● Wound culture revealed very light growth of non-fermenting organism which
was sensitive to cloxacillin.
 Biopsy of lesion
Skin punch biopsy of an early vesicle revealed a subepidermal blister with neutrophilic
predominance that was consistent with DH versus linear IgA bullous dermatosis.
Direct Immunofluorescence (DIF) from a perilesional normal skin showed positive
granular IgA deposits at the tips of the dermal papillae that is consistent of DH
Management
● He was started with cloxacillin and mupirocin ointment for one week for the
infected skin lesions.
● The patient was on loratadine 10 mg/tab once a day for pruritus.
● He was started on dapsone 100 mg/tab once a day after G-6-PD test revealed
a normal result. Complete blood count was regularly monitored.
● The patient was also started on Gluten-Free-Diet. He was referred to a
nutritionist and was advised to avoid the following food such as egg noodle,
macaroni, miki, misua, sotanghon, spaghetti, sausages, instant coffee, gluten-
containing milk powder, cereal, beer and wheat bread.
 Follow-up
On the ninth week of
therapy, the skin lesions
were completely resolved
with residual hypo- and
hyperpigmented macules
and patches. Finally, the
patient was diagnosed to
have dermatitis
herpetiformis.
Case Discussion
● DH is auto-immune disorder associated with gluten enteropathy in 90% cases,
but less than 20% people have GI symptoms of celiac disease
● The earliest symptom in these patients is the rash- rather than the GI
symptoms
● Only 5% first degree relatives of a person with DH will have DH
● DH is more common in northern Europeans, but can occur in other ethnicities
● It will take around two years of GFD for a complete resolution of cutaneous
lesions, which can recur within 12 weeks after the reintroduction of gluten
● Because GFD takes a long time for a response to occur, a concurrent use of
dapsone is usually necessary
● Dapsone can cause hemolytic anemia in those susceptible, hence monitoring of
Hb is necessary
Thank you