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Fernández-Bañares F, Crespo L, Planella M, Farrais S, Izquierdo S, López-Palacios N, Roy G, Vidal J, Núñez C. Improving the Diagnosis of Dermatitis Herpetiformis Using the Intraepithelial Lymphogram. Nutrients 2024; 16:232. [PMID: 38257124 PMCID: PMC10819692 DOI: 10.3390/nu16020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Dermatitis herpetiformis is a cutaneous manifestation of celiac disease. Phenotyping of intraepithelial lymphocytes in the small bowel mucosa can strengthen the diagnosis of celiac disease when it is not clear-cut. We aim to evaluate the usefulness of the intraepithelial lymphogram to confirm dermatitis herpetiformis in equivocal cases. We performed a retrospective multicenter study on patients diagnosed with dermatitis herpetiformis and collected data from the intraepithelial lymphogram assessed by flow cytometry. A total of 36 patients were analyzed in relation to the severity of intestinal damage (18 had non-atrophic mucosa) at baseline (N = 28) and/or after the adoption of a gluten-free diet (median follow-up of three years, N = 16). We observed that patients with atrophy more often had positive celiac serology (p = 0.019), celiac clinical symptoms (p = 0.018), and iron-deficiency anemia (p = 0.018), but the severity of skin damage was similar in both groups (p = 0.79). At baseline, increased TCRγδ+ cells were present in 94% of patients with atrophy and 67% with non-atrophic lesions (p = 0.13). After a gluten-free diet, increased TCRγδ+ cells persisted in 100% and 63% of cases, respectively (p = 0.21). We concluded that increased TCRγδ+ cells may be helpful in confirming the diagnosis of dermatitis herpetiformis in equivocal cases, even in patients who were started on a gluten-free diet.
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Affiliation(s)
- Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrasa, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laura Crespo
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Montserrat Planella
- Department of Gastroenterology, Hospital Arnau Vilanova, 25198 Lleida, Spain;
| | - Sergio Farrais
- Department of Gastroenterology, Hospital Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Sandra Izquierdo
- Department of Gastroenterology, Hospital Clínico Universitario, 47003 Valladolid, Spain;
| | - Natalia López-Palacios
- Department of Gastroenterology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Garbiñe Roy
- Department of Immunology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, 28034 Madrid, Spain;
| | - Judith Vidal
- Section of Flow Cytometry, CATLAB, 08232 Viladecavalls, Spain;
| | - Concepción Núñez
- Laboratorio de Investigación en Genética de Enfermedades Complejas, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, 28040 Madrid, Spain
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), 28029 Madrid, Spain
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Albadri Z, Al Bayati D, Häbel H, Jerkovic Gulin S, Grönhagen C, Seifert O. Incidence of Dermatitis Herpetiformis in Sweden 2005 to 2018: A Nationwide Retrospective Cohort Study. Acta Derm Venereol 2023; 103:adv13210. [PMID: 37971253 PMCID: PMC10666066 DOI: 10.2340/actadv.v103.13210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
Dermatitis herpetiformis has been investigated in the past; however, only a limited number of studies have reported its incidence based on validated nationwide population-based registries. To address this gap, the aims of this study are to estimate the incidence of dermatitis herpetiformis in Sweden and to validate the National Patient Register (NPR) for diagnosis of dermatitis herpetiformis. A population-based open cohort study was conducted, including all patients diagnosed with dermatitis herpetiformis (International Classification of Diseases 10th revision; ICD-10 code L13.0) in Sweden from 2005 to 2018 (n = 1,724), identified from the NPR. The diagnosis of dermatitis herpetiformis in the NPR was validated using medical records, histopathological and immunopathological data, yielding a positive predictive value (PPV) of 62.5%. The mean annual incidence of dermatitis herpetiformis was 0.93/100,000 (95% confidence interval 0.79-1.08), female to male ratio 1:1, and mean age at diagnosis 60.9 years. In conclusion, this large nationwide cohort study showed a low validity for diagnosis of dermatitis herpetiformis in the NPR, and the adjusted incidence rate of dermatitis herpetiformis in Sweden was estimated to be 0.93/100,000, which is lower than that in previous Swedish studies.
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Affiliation(s)
- Zeyad Albadri
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Doua Al Bayati
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Henrike Häbel
- Medical Statistics Unit, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Sandra Jerkovic Gulin
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Division of Dermatology and Venereology, Region Jönköping County, Jönköping, Sweden
| | - Carina Grönhagen
- Department of Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Oliver Seifert
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Chakraborty A. Disease severity scores in dermatology: An update of the various indices. Indian J Dermatol Venereol Leprol 2023; 0:1-15. [PMID: 37436018 DOI: 10.25259/ijdvl_592_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/15/2022] [Indexed: 07/13/2023]
Affiliation(s)
- Atreyo Chakraborty
- Department of Dermatology Venereology & Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Verdelli A, Corrà A, Mariotti EB, Aimo C, Quintarelli L, Ruffo di Calabria V, Donati ME, Bonciolini V, Antiga E, Caproni M. Skin gluten-related disorders: new and old cutaneous manifestations to be considered. Front Med (Lausanne) 2023; 10:1155288. [PMID: 37265490 PMCID: PMC10229844 DOI: 10.3389/fmed.2023.1155288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
The term gluten-related disorders (GRD) refer to a spectrum of different clinical manifestations triggered by the ingestion of gluten in genetically susceptible individuals, including coeliac disease (CD), wheat allergy and non-celiac gluten sensitivity (NCGS). GRD are characterized by a large variety of clinical presentations with both intestinal and extra-intestinal manifestations. The latter may affect almost every organ of the body, including the skin. Besides the well-known association between CD and dermatitis herpetiformis, considered as the cutaneous specific manifestation of CD, many other muco-cutaneous disorders have been associated to GRD. In this review, we analyzed the main features of dermatological diseases with a proven association with GRD and those that improve after a gluten-free diet, focusing on the newly described cutaneous manifestations associated with NCGS. Our main hypothesis is that a "cutaneous-gluten sensitivity," as specific cutaneous manifestation of NCGS, may exist and could represent a diagnostic marker of NCGS.
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Affiliation(s)
- Alice Verdelli
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
| | - Alberto Corrà
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Cristina Aimo
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Lavinia Quintarelli
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
| | | | - Marta Elettra Donati
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Marzia Caproni
- Department of Health Sciences, Rare Dermatological Diseases Unit, Azienda USL Toscana Centro, European Reference Network-Skin Member, Florence, Italy
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Schauer F, Tasiopoulou G, Schuster D, Behrens M, Müller S, Kiritsi D. Primate liver tissue substrate in indirect immunofluorescence diagnostics for patients with dermatitis herpetiformis and celiac disease. Front Immunol 2023; 14:1104360. [PMID: 36875085 PMCID: PMC9977789 DOI: 10.3389/fimmu.2023.1104360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Dermatitis herpetiformis (DH) is a rare autoimmune, polymorphous blistering disorder, characterized by severe itch or burning sensation, which represents the cutaneous manifestation of celiac disease (CD). The current estimation of DH versus CD is around 1:8 and the affected individuals have a genetic predisposition. Pathogenetically, IgA autoantibodies against the epidermal transglutaminase, an essential constituent of the epidermis, cause DH and are reported to develop through cross-reaction with the tissue transglutaminase, with IgA auto-antibodies causing CD. Immunofluorescence techniques allow for a rapid diagnostics of the disease using patient sera. Evaluation of IgA endomysial deposition with indirect immunofluorescence on monkey oesophagus is highly specific, but moderately sensitive, with some operator-dependent variability. Recently, indirect immunofluorescence with monkey liver as a substrate has been proposed as an alternative, well-functioning diagnostic approach with higher sensitivity in CD. Methods The objective of our study was to evaluate whether monkey oesophagus or liver tissue shows advantage for diagnostics in patients with DH, compared to CD. To that end, sera of 103 patients with DH (n=16), CD (n=67) and 20 controls ere compared by 4 blinded experienced raters. Results For DH, we found a sensitivity of 94.2% for monkey liver (ML) compared to 96.2% in monkey oesophagus (ME), while specificity in ML was superior (91.6% versus 75%) to ME. In CD, ML had a sensitivity of 76.9% (ME 89.1%) and specificity of 98.3% (ME 94.1%). Discussion Our data show that ML substrate is well suitable for DH diagnostics.
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Affiliation(s)
- Franziska Schauer
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georgia Tasiopoulou
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Schuster
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Max Behrens
- Institute of Medical Biometry and Statistics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sabine Müller
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Pasternack C, Hervonen K, Mansikka E, Reunala T, Kaukinen K, Salmi T. Sex-differences in Gluten-free Dietary Adherence and Clinical Symptoms in Patients with Long-term Treated Dermatitis Herpetiformis. Acta Derm Venereol 2022; 102:adv00713. [PMID: 35393627 PMCID: PMC9558333 DOI: 10.2340/actadv.v102.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dermatitis herpetiformis is a blistering autoimmune skin disease, and a cutaneous manifestation of coeliac disease. The burden of coeliac disease is increased especially in females, but studies concerning sex differences in patients with long-term treated dermatitis herpetiformis are scarce. This questionnaire study compared adherence to a gluten-free diet, clinical symptoms and well-being between females and males in a cohort of 237 long-term treated (median 24 years) patients with dermatitis herpetiformis. Females had better adherence to a gluten-free diet (p = 0.022) and they used dapsone significantly less often at the time of the study than did males (4% vs 13%, p = 0.017). The occurrence of skin symptoms was equal in both sexes, but dermatological quality of life was lower in females (p = 0.024), and gastrointestinal symptoms were more severe among females with dermatitis herpetiformis than among males (p = 0.027). In conclusion, long-term treated female patients with dermatitis herpetiformis have better adherence to a gluten-free diet, but they also experience more severe clinical symptoms compared with males.
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Affiliation(s)
- Camilla Pasternack
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Dermatitis Herpetiformis: An Update on Diagnosis, Disease Monitoring, and Management. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080843. [PMID: 34441049 PMCID: PMC8400185 DOI: 10.3390/medicina57080843] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022]
Abstract
Dermatitis herpetiformis (DH), Duhring disease, is caused by gluten sensitivity and affects 11.2 to 75.3 per 100,000 people in the United States and Europe with an incidence of 0.4 to 3.5 per 100,000 people per year. DH is characterized by a symmetrical blistering rash on the extensor surfaces with severe pruritus. The diagnosis continues to be made primarily by pathognomonic findings on histopathology, especially direct immunofluorescence (DIF). Recently, anti-epidermal transglutaminase (TG3) antibodies have shown to be a primary diagnostic serology, while anti-tissue transglutaminase (TG2) and other autoantibodies may be used to support the diagnosis and for disease monitoring. Newly diagnosed patients with DH should be screened and assessed for associated diseases and complications. A gluten-free diet (GFD) and dapsone are still mainstays of treatment, but other medications may be necessary for recalcitrant cases. Well-controlled DH patients, managed by a dermatologist, a gastroenterologist, and a dietician, have an excellent prognosis. Our review comprehensively details the current diagnostic methods, as well as methods used to monitor its disease course. We also describe both the traditional and novel management options reported in the literature.
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Gornowicz-Porowska J, Seraszek-Jaros A, Jałowska M, Bowszyc-Dmochowska M, Kaczmarek E, Dmochowski M. Evaluation of a Bi-Analyte Immunoblot as a Useful Tool for Diagnosing Dermatitis Herpetiformis. Diagnostics (Basel) 2021; 11:diagnostics11081414. [PMID: 34441348 PMCID: PMC8392659 DOI: 10.3390/diagnostics11081414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022] Open
Abstract
Immune responses to tissue transglutaminase (tTG) and nonapeptides of gliadin (npG) are associated with dermatitis herpetiformis (DH), a gluten-related dermatosis. Recently, a bi-analyte immunoblot (b-aIB) was introduced to detect IgA antibodies in response to tTG and npG. We compared the utility of ELISA and b-aIB with tTG in serological diagnoses of DH and their agreement with direct immunofluorescence (DIF). In total, 55 sera (27 DIF-positive DH patients, 4 DIF-negative DH patients and 24 healthy controls) were examined. ELISA for anti-tTG IgA, b-aIB for anti-npG and anti-tTG IgA, and statistical analysis were performed. The b-aIB with tTG showed 78% sensitivity, 100% specificity, 100% positive predictive value, and 82% negative predictive value in relation to ELISA. A better rate of agreement (Cohen’s kappa values) in IgA detection was observed in the pair tTG ELISA and b-aIB with npG (0.85) than in pairs tTG ELISA and b-aIB with tTG (0.78) or b-aIB with tTG and b-aIB with npG (0.78). No degree of agreement was found between serological tests and DIF. Both serological tests may be used to detect the anti-tTG IgA in DH patients. Still, DH diagnosing requires careful consideration of clinical data as well as results of tissue imaging (crucial DIF) and immunoserological techniques detecting DH-type features.
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Affiliation(s)
- Justyna Gornowicz-Porowska
- Department and Division of Practical Cosmetology and Skin Diseases Prophylaxis, Poznan University of Medical Sciences, 33 Mazowiecka Street, 60-623 Poznań, Poland
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
- Correspondence: ; Tel.: +4861-869-13-67
| | - Agnieszka Seraszek-Jaros
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, 4 Rokietnicka Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Magdalena Jałowska
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland;
| | - Elżbieta Kaczmarek
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, 4 Rokietnicka Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznań, Poland; (M.J.); (M.D.)
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Görög A, Antiga E, Caproni M, Cianchini G, De D, Dmochowski M, Dolinsek J, Drenovska K, Feliciani C, Hervonen K, Lakos Jukic I, Kinyó Á, Koltai T, Korponay-Szabó I, Marzano AV, Patsatsi A, Rose C, Salmi T, Schmidt E, Setterfield J, Shahid M, Sitaru C, Uzun S, Valitutti F, Vassileva S, Yayli S, Sárdy M. S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2021; 35:1251-1277. [PMID: 34004067 DOI: 10.1111/jdv.17183] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH. METHODS The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF). RESULTS The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix). CONCLUSION These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.
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Affiliation(s)
- A Görög
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - E Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - M Caproni
- Rare Diseases Unit, Section of Dermatology, Department of Health Sciences, USL Toscana Centro, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - G Cianchini
- Department of Dermatology, Cristo Re Hospital, Rome, Italy
| | - D De
- Department of Dermatology, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - M Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznań, Poland
| | - J Dolinsek
- Gastroenterology Unit, Department of Pediatrics, University Medical Center Maribor, Maribor, Slovenia.,Medical Faculty, University of Maribor, Maribor, Slovenia
| | - K Drenovska
- Department of Dermatology and Venereology, Medical University, Sofia, Bulgaria
| | - C Feliciani
- Dermatology Unit Azienda Ospedaliero - Universitaria, Università di Parma, Parma, Italy
| | - K Hervonen
- Coeliac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | - I Lakos Jukic
- Department of Dermatology and Venereology, University Hospital Center Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Á Kinyó
- Department of Dermatology, Venereology and Oncodermatology, University of Pécs Medical School, Pécs, Hungary
| | - T Koltai
- Association of European Coeliac Societies, Brussels, Belgium.,Hungarian Coeliac Society, Budapest, Hungary
| | - I Korponay-Szabó
- Coeliac Disease Centre, Heim Pál National Paediatric Institute, Budapest, Hungary.,Faculty of Medicine, Institute of Paediatrics, University of Debrecen, Debrecen, Hungary
| | - A V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - A Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Dermatology Department, Aristotle University School of Medicine, Thessaloniki, Greece
| | - C Rose
- Dermatopathology Laboratory, Lübeck, Germany.,German Coeliac Disease Society e. V., Stuttgart, Germany
| | - T Salmi
- Coeliac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - J Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Host Microbiome Interactions, Faculty of Dentistry Oral & Craniofacial Sciences, King's College London, London, UK
| | - M Shahid
- Department of Dermatology and Venereology, Medical University, Sofia, Bulgaria
| | - C Sitaru
- Department of Dermatology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,BIOSS Centre for Biological Signalling, University of Freiburg, Freiburg, Germany
| | - S Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - F Valitutti
- Pediatric Unit, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - S Vassileva
- Department of Dermatology and Venereology, Medical University, Sofia, Bulgaria
| | - S Yayli
- Department of Dermatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - M Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary.,Department of Dermatology and Allergy, University Hospital of LMU, Munich, Germany
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