Dermatitis herpetiformis: Gluten-free diet, dapsone therapy cornerstone approach

Key Points

In those genetically predisposed individuals, gliadin found in glutens is widely accepted as the antigenic trigger that causes dermatitis herpetiformis or Duhring's disease. This principal wheat protein is also associated with other disorders such as Celiac disease (gluten sensitive enteropathy) and gastrointestinal lymphomas (non-Hodgkin's) as well as several autoimmune diseases including autoimmune thyroid disease, lupus erythematosus, vitiligo and Sjögren's syndrome.

Gluten-free diet

Though not the rule, some patients may experience a remission and are able to return to a normal diet. According to the literature, this occurs in approximately 10 percent to 20 percent of patients with gluten sensitivity. Within a couple of months, it will be very clear to the patient as to whether or not they can tolerate a normal diet.

"Many patients with dermatitis herpetiformis will assume that they will have to adapt to a life-long modification of their diet and this is simply not true for all cases. If a gluten-free diet is ineffective or if the patient does not want to follow this diet modification, dapsone is readily used to treat these patients," says Warren R. Heymann M.D., professor of medicine and pediatrics and head of the division of dermatology, University of Medicine and Dentistry of New Jersey, Camden, New Jersey.

Dapsone

Dapsone is the only Food and Drug Administration (FDA) approved drug used in the treatment of dermatitis herpetiformis and is the drug of choice if a gluten-free diet modification is not an option, for whatever reason. Patients respond very well to dapsone with pruritus improving within 24 to 48 hours and the papulovesicular lesions improving within a week of therapy induction.

Recently, 5 percent dapsone gel (Aczone) has become available for the treatment of dermatitis herpetiformis. To date, there have not been any studies on topical dapsone, however, according to Dr. Heymann, there may be certain scenarios where the patient could benefit from a topical approach.

"Theoretically, systemic dapsone could be used initially and topical therapy could be then continued as a maintenance therapy, depending on the extent of the symptoms of dermatitis herpetiformis, but this still remains to be seen. There are patients who can have very extensive disease over large body surface areas. Topical dapsone will likely be useful only in those patients where disease extent is localized or minimal. It would not make sense to use it in extensive disease, as there is no data supporting this approach," Dr. Heymann says.