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Wan Y, Zhang L, Xie B, Wu J, Zhao M, Guo J, Ding J. Impetigo herpetiformis in the second trimester: a case report and review of the literature. J Int Med Res 2023; 51:3000605231217950. [PMID: 38102997 PMCID: PMC10725655 DOI: 10.1177/03000605231217950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Impetigo herpetiformis is a rare skin disease that most often occurs in the third trimester of pregnancy. It is currently considered as a form of generalized pustular psoriasis and the typical skin lesions comprise small sterile pustules. Here, a case of impetigo herpetiformis in the second trimester of pregnancy after 7 weeks of hydroxychloroquine administration for suspected Sjogren's syndrome is reported. Treatment with anti-infective, anti-inflammatory and immunosuppressive medication did not improve the patient's condition. Following delivery of a live male by emergency caesarean section at 29 weeks' gestation, the rash was reported to be completely resolved by 3 months postpartum. Previously published cases of impetigo herpetiformis in the second trimester of pregnancy that were retrieved from a search of the PubMed database are also reviewed and discussed.
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Affiliation(s)
- Yingcai Wan
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Lei Zhang
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Boyu Xie
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jianbo Wu
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Mengjie Zhao
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Juanjuan Guo
- Department of Obstetrics and Gynaecology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Juan Ding
- Department of Dermatology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
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Mania-Końsko A, Szponar E, Dańczak-Pazdrowska A, Bowszyc-Dmochowska M, Pazdrowski J, Wyganowska M. Immunopathological Assessment of the Oral Mucosa in Dermatitis Herpetiformis. Int J Environ Res Public Health 2023; 20:2524. [PMID: 36767890 PMCID: PMC9915384 DOI: 10.3390/ijerph20032524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
Dermatitis herpetiformis (Duhring's disease, DH) is a chronic blistering cutaneous condition with pruritic polymorphic lesions, consisting of vesicles, papules or nodules and erythema, found predominantly on the extensor surfaces of the limbs, buttocks, and neck. Diagnosis is based on characteristic clinical and immunopathological findings. Oral manifestations of DH have rarely been described. The aim of the study was to evaluate IgA, IgG, IgM and C3 complement deposits in the oral mucosa in DH patients. Direct immunofluorescence (DIF) was performed on the oral mucosa specimens collected from 10 DH patients. Biopsy was taken in a local anesthesia from perilesional site from the buccal mucosa and then preserved in a standard procedure using polyclonal rabbit IgG, IgA, IgM and C3 antibodies. Granular IgA and C3 deposits were found in 6 patients (60%), and in 3 subjects (30%) the result was indeterminate. Significant fluorescence of the deposits along the basement membrane was observed in 2 patients, moderate fluorescence in 3 patients, and in 4 cases the result was indeterminate. C3 deposits were found in 5 subjects (50%), 3 of them being moderate and 2 indeterminate. No IgM and IgG deposits were detected in the collected buccal mucosa specimens.
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Affiliation(s)
- Agnieszka Mania-Końsko
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
| | - Elżbieta Szponar
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
| | | | - Monika Bowszyc-Dmochowska
- Department of Dermatology, Poznan University of Medical Sciences, 49, Przybyszewskiego St., 61-701 Poznań, Poland
| | - Jakub Pazdrowski
- The Maria Skłodowska-Curie Greater Poland Cancer Center, Department of Head and Neck Surgery, Poznan University of Medical Sciences, Garbary St., 61-701 Poznań, Poland
| | - Marzena Wyganowska
- Department of Dental Surgery, Periodontology and Oral Mucosa Diseases, Poznan University of Medical Sciences, 70, Bukowska St., 60-812 Poznań, Poland
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Kaunisto H, Salmi T, Lindfors K, Kemppainen E. Antibody Responses to Transglutaminase 3 in Dermatitis Herpetiformis: Lessons from Celiac Disease. Int J Mol Sci 2022; 23:ijms23062910. [PMID: 35328331 PMCID: PMC8953297 DOI: 10.3390/ijms23062910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/13/2022] Open
Abstract
Dermatitis herpetiformis (DH) is the skin manifestation of celiac disease, presenting with a blistering rash typically on the knees, elbows, buttocks and scalp. In both DH and celiac disease, exposure to dietary gluten triggers a cascade of events resulting in the production of autoantibodies against the transglutaminase (TG) enzyme, mainly TG2 but often also TG3. The latter is considered to be the primary autoantigen in DH. The dynamics of the development of the TG2-targeted autoimmune response have been studied in depth in celiac disease, but the immunological process underlying DH pathophysiology is incompletely understood. Part of this process is the occurrence of granular deposits of IgA and TG3 in the perilesional skin. While this serves as the primary diagnostic finding in DH, the role of these immunocomplexes in the pathogenesis is unknown. Intriguingly, even though gluten-intolerance likely develops initially in a similar manner in both DH and celiac disease, after the onset of the disease, its manifestations differ widely.
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Affiliation(s)
- Helka Kaunisto
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
- Department of Dermatology, Tampere University Hospital, FI-33520 Tampere, Finland
| | - Katri Lindfors
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
| | - Esko Kemppainen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland; (H.K.); (T.S.); (K.L.)
- Correspondence:
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Affiliation(s)
- Adelina Costin
- Dermatology and Venereology Service, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Marta António
- Dermatology and Venereology Service, Hospital Garcia de Orta, Almada, Portugal
| | - Constança Furtado
- Dermatology and Venereology Service, Hospital Garcia de Orta, Almada, Portugal
| | - Elvira Bártolo
- Dermatology and Venereology Service, Hospital Garcia de Orta, Almada, Portugal
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Mansikka E, Hervonen K, Kaukinen K, Ilus T, Oksanen P, Lindfors K, Laurila K, Hietikko M, Taavela J, Jernman J, Saavalainen P, Reunala T, Salmi T. Gluten Challenge Induces Skin and Small Bowel Relapse in Long-Term Gluten-Free Diet-Treated Dermatitis Herpetiformis. J Invest Dermatol 2019; 139:2108-2114. [PMID: 30998982 DOI: 10.1016/j.jid.2019.03.1150] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 01/20/2023]
Abstract
Dermatitis herpetiformis (DH) is an extraintestinal manifestation of celiac disease causing an itchy, blistering rash. Granular IgA deposits in the skin are pathognomonic for DH, and the treatment of choice is a lifelong gluten-free diet (GFD). Preliminary evidence suggests that there are patients with DH who redevelop gluten tolerance after adherence to a GFD treatment. To evaluate this, we performed a 12-month gluten challenge with skin and small-bowel mucosal biopsy samples in 19 patients with DH who had adhered to a GFD for a mean of 23 years. Prechallenge biopsy was negative for skin IgA and transglutaminase 3 deposits in 16 patients (84%) and indicated normal villous height-to-crypt depth ratios in the small bowel mucosa in all 19 patients. The gluten challenge caused a relapse of the rash in 15 patients (79%) in a mean of 5.6 months; of these 15 patients, 13 had skin IgA and transglutaminase 3 deposits, and 12 had small-bowel villous atrophy. In addition, three patients without rash or immune deposits in the skin developed villous atrophy, whereas one patient persisted without any signs of relapse. In conclusion, 95% of the patients with DH were unable to tolerate gluten even after long-term adherence to a GFD. Therefore, lifelong GFD treatment remains justified in all patients with DH.
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Affiliation(s)
- Eriika Mansikka
- Department of Dermatology, Tampere University Hospital, Tampere, Finland; Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Kaisa Hervonen
- Department of Dermatology, Tampere University Hospital, Tampere, Finland; Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Tuire Ilus
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Pia Oksanen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Katri Lindfors
- Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Kaija Laurila
- Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Minna Hietikko
- Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Juha Taavela
- Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; Department of Internal Medicine, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Juha Jernman
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki, Finland; Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
| | - Timo Reunala
- Department of Dermatology, Tampere University Hospital, Tampere, Finland; Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Teea Salmi
- Department of Dermatology, Tampere University Hospital, Tampere, Finland; Celiac Disease Research Center, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.
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Wang Y, Yang B, Zhou G, Zhang F. Two Cases of Dermatitis Herpetiformis Successfully Treated with Tetracycline and Niacinamide. Acta Dermatovenerol Croat 2018; 26:273-275. [PMID: 30390734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Dear Editor, Dermatitis herpetiformis (DH) is a chronic, polymorphic, pruritic autoimmune blistering skin disease characterized by subepidermal blisters, neutrophilic microabscesses, and granular IgA deposition within the dermal papillae. DH is classified as a cutaneous manifestation of coeliac disease, a type of gluten-sensitive enteropathy (1). The treatment of DH includes dapsone and a gluten-free diet (GFD). Other therapies should be considered in patients who are unable to tolerate dapsone, including sulfapyridine and glucocorticoids. Herein we present two cases of DH with good responses to tetracycline and niacinamide combination therapy. Case 1 was a 42-year-old man who was admitted to our hospital with a 3-year history of recurrent pruritic papules and bullous lesions involving the trunk and upper limbs. On examination, the patient showed disseminated erythematous papules on the upper limbs and back as well as vesicles. Nikolsky's sign for vesicles was negative (Figure 1, a-c). The results of routine blood examinations were within normal ranges. He did not have a history of chronic diarrhea. The histologic examination showed subepidermal blisters and accumulation of neutrophils at the papillary dermis of the involved ski. Direct immunofluorescence revealed fibrillar deposition of IgA on the dermal papillae (Figure 1. g, h). Case 2 was a 34-year-old woman who had a history of skin rash and pruritic lesions predominantly involving the arms and legs, which had been present for 10 months. She had been treated with prednisone (30 mg daily) with improvement; however, the lesions reappeared when the prednisone was discontinued. She had a history of constipation. On physical examination, the skin lesions manifested as erythematous papules, vesicles, and scabs on the limbs (Figure 2. a-c). She felt apparently pruritic. The histologic examination of the biopsy identified subepidermal blisters with a neutrophil infiltrate in the upper dermis. Direct immunofluorescence revealed granular deposition of IgA on the dermal papillae (Figure 2. e, f). The results of routine blood examinations were within normal ranges, with the exception of elevated IgE concentration (222.5 ku/L (normal range, 0-100 ku/L)). The clinical manifestations and histologic and immunofluorescence examinations of the two cases confirmed the diagnosis of DH. The two patients were subsequently started on a strict GFD. At that time, dapsone was not available in the hospital. The patients were treated with oral tetracycline (500 mg four times daily) and nicotinamide (500 mg three times daily). The rash affecting case 1 resolved entirely in 2 weeks. The patient discontinued the medications after 6 months, and occasionally presented with a few pruritic papules and vesicles, but the lesions resolved within 1 week. The lesions affecting case 2 completely healed within 1 month. The patient continued taking those medications and no recurrence of the skin lesions occurred during 2 years of follow-up. Dapsone is considered first-line therapy for patients with DH (2). Recent findings have shown dapsone and lower dosages of sulfasalazine combination therapy in DH are effective and well-tolerated (3). Alternative monotherapeutic agents in mild autoimmune bullous diseases such as DH include a tetracycline group of antibiotics with niacinamide or its derivatives as well as sulfasalazine. Because dapsone is difficult to obtain in China except for patients with leprosy, we treated the patients with tetracycline and nicotinamide. To our knowledge, only a few cases of DH have been successfully treated with oral tetracycline and niacinamide (2,4). One of the patients was also prescribed heparin (4). Tetracycline has anti-inflammatory properties due to the inhibition of metalloproteinase activity and mast cell activation (5). Nicotinamide is a potent modulator of several pro-inflammatory cytokines. Nicotinamide can inhibit cytokine release (IL-1, IL-6, IL-8, and TNF-α) from immune cells, inhibit chemotaxis and degranulation of immune cells, inhibit lymphocyte blast transformation, and suppress T-cell activity (6). The non-antibiotic properties of tetracycline in combination with nicotinamide may participate in inhibition of antibody formation, modulation of pro-inflammatory cytokines, inflammatory cell accumulation, lymphocyte transformation, and T-cell activation. In summary, we reported two typical cases of DH that were successfully treated with oral tetracycline and niacinamide, which completely healed the rash and relieved the symptoms within 1 month. The combination of tetracycline and nicotinamide can be recommended as a useful therapy for patients where dapsone is not available or for patients who do not tolerate dapsone.
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Affiliation(s)
| | - Baoqi Yang
- Baoqi Yang, MD, Department of Dermatology Shandong Provincial Institute of Dermatology and Venereology Shandong Academy of Medical Sciences 27397 Jingshi Road, Jinan, Shandong, 250022, China;
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Mansikka E, Salmi T, Kaukinen K, Collin P, Huhtala H, Reunala T, Hervonen K. Diagnostic Delay in Dermatitis Herpetiformis in a High-prevalence Area. Acta Derm Venereol 2018; 98:195-199. [PMID: 29048096 DOI: 10.2340/00015555-2818] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dermatitis herpetiformis (DH) is an extra-intestinal manifestation of coeliac disease. The highest currently reported prevalence of DH is in Finland, but knowledge of diagnostic delay is limited. This study investigated the duration of rash prior to diagnosis in 446 patients with DH, analysing the results in 3 periods of 15 years. The diagnosis was considered delayed when the duration of rash before diagnosis was 2 years or longer. Factors associated with delayed diagnosis were analysed. Within the 45 years, the median duration of rash before diagnosis decreased significantly, from 12.0 to 8.0 months (p?=?0.002) and the occurrence of a delayed diagnosis decreased from 47% to 25% (p?=?0.002). Female sex, the presence of villous atrophy, and a diagnosis of DH before the year 2000 were significantly associated with delayed diagnosis. In conclusion, the present study showed that one-quarter of patients currently have a diagnostic delay of 2 years or more, which is far from ideal.
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Affiliation(s)
- Eriika Mansikka
- Department of Dermatology, Tampere University Hospital, PO Box 2000, FIN-33521 Tampere, Finland
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Abstract
Impetigo herpetiformis (pustular psoriasis of pregnancy) is a rare dermatosis of pregnancy that typically starts in the 2nd half of pregnancy and resolves postpartum. It may recur in subsequent pregnancies. I present a case of 23 year old female gravida 4 para 3 with recurrent impetigo herpetiformis at 26 weeks gestation. She presented with a one month history of pustular lesions which responded to treatment with prednisone. She delivered at term with a favourable outcome. The disease resolved one month postpartum. This was the second recurrence of the disease. She had her first episode of impetigo herpetiformis during the second pregnancy. The disease recurred in the 3rd pregnancy and resulted in a still birth.
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Ansai O, Shimomura Y, Fujimoto A, Sakai A, Tsuchida Y, Hayashi R, Shigehara Y, Hama N, Abe R. Case of pemphigus herpetiformis with immunoglobulin G autoantibodies against desmocollin-3. J Dermatol 2017; 44:104-105. [PMID: 27177601 DOI: 10.1111/1346-8138.13451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Osamu Ansai
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yutaka Shimomura
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Atsushi Fujimoto
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akari Sakai
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuko Tsuchida
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ryota Hayashi
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yohya Shigehara
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Baptista A, Madanelo S, Morais P. A pruritic vesicular rash. Aust Fam Physician 2017; 46:45-47. [PMID: 28189132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Hashimoto T, Tsuruta D, Yasukochi A, Imanishi H, Sekine H, Fujita T, Wanibuchi H, Gi M, Kárpáti S, Sitaru C, Zone JJ, Endo D, Abe S, Nishino T, Koji T, Ishii N. Granular C3 Dermatosis. Acta Derm Venereol 2016; 96:748-53. [PMID: 26912390 DOI: 10.2340/00015555-2379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There has been no previous systematic study of bullous skin diseases with granular basement membrane zone deposition exclusively of C3. In this study we collected 20 such patients, none of whom showed cutaneous vasculitis histopathologically. Oral dapsone and topical steroids were effective. Various serological tests detected no autoantibodies or autoantigens. Direct immunofluorescence for various complement components revealed deposition only of C3 and C5-C9, indicating that no known complement pathways were involved. Studies of in situ hybridization and micro-dissection with quantitative RT-PCR revealed a slight reduction in expression of C3 in patient epidermis. These patients may represent a new disease entity, for which we propose the term "granular C3 dermatosis". The mechanism for granular C3 deposition in these patients is unknown, but it is possible that the condition is caused by autoantibodies to skin or aberrant C3 expression in epidermal keratinocytes.
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Affiliation(s)
- Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, 830-0011 Kurume, Japan.
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12
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Affiliation(s)
- T Reunala
- Department of Dermatology and Clinical Sciences, University Hospital, Finland
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Braswell MA, McCowan NK, Schulmeier JS, Brodell RT. High-yield biopsy technique for subepidermal blisters. Cutis 2015; 95:237-240. [PMID: 25942026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Dermatologists often perform 2 biopsies in patients with widespread tense blisters: one for light microscopy and another for direct immunofluorescence (DIF). Biopsy techniques recommended for blistering diseases with tense blisters are discussed, and illustrations demonstrate an alternative approach utilizing a single punch biopsy. A single punch biopsy is more cost effective and provides the same diagnostic information as the standard 2-biopsy approach for subepidermal blisters plus additional salt-split skin-like diagnostic information. A limitation for bisecting the single punch biopsy specimen is a potential complete separation of the epidermis from the dermis. The single punch biopsy technique is a simple cost-effective method for obtaining necessary diagnostic information when sampling tense blisters in patients with blistering diseases.
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Affiliation(s)
| | | | | | - Robert T Brodell
- Division of Dermatology, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA.
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Yost JM, Hale CS, Meehan SA, McLellan BN. Dermatitis herpetiformis. Dermatol Online J 2014; 20:13030/qt4kg43857. [PMID: 25526342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 06/04/2023] Open
Abstract
Dermatitis herpetiformis (DH) is an autoimmune bullous disease, which represents the cutaneous manifestation of gluten sensitivity, in the setting of celiac disease. Although classical DH is characterized clinically by grouped, vesicles on an erythematous base, primary lesions often are absent owing to the intense, associated pruritus. Instead, many cases present only with erythematous erosions with numerous overlying excoriations. As in celiac disease, the core pathogenic mechanisms of DH are likely mediated by immunoglobulin A class autoantibodies against one of several transglutaminase enzymes. As the production of these autoantibodies is directly correlated with gastrointestinal exposure to gliadin, which is an alcohol-soluble fraction of gluten, a gluten-free diet represents the cornerstone of a DH management regimen. In cases refractory to dietary management alone, dapsone is the first-line agent for the treatment of DH, although many other agents have been anecdotally reported as effective.
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Kotze LMDS, Vecchia LA, Nisihara R, Kotze LR. Dermatitis herpetiformis in Brazilan male celiac disease patients: A case series. Rev Esp Enferm Dig 2014; 106:562-564. [PMID: 25544421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Stephan F, Haber R, Maalouf D, Tomb R. A case of dermatitis herpetiformis after a mini-gastric bypass surgery. J Am Acad Dermatol 2014; 71:e18-20. [PMID: 24947705 DOI: 10.1016/j.jaad.2014.01.854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/05/2014] [Accepted: 01/07/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Farid Stephan
- Department of Dermatology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Roger Haber
- Department of Dermatology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Diane Maalouf
- Department of Dermatology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
| | - Roland Tomb
- Department of Dermatology, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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Jakes AD, Bradley S, Donlevy L. [Dermatitis herpetiformis Duhring]. Praxis (Bern 1994) 2014; 103:1085-1088. [PMID: 25183618 DOI: 10.1024/1661-8157/a001764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Adam D Jakes
- Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, Grossbritannien
| | - Stephen Bradley
- Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, Grossbritannien
| | - Lynn Donlevy
- Silsden Group Medical Practice, Keighley, Grossbritannien
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19
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Affiliation(s)
- Adam D Jakes
- Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
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Quaglino P, Ponti R, Novelli M, Savoia P, Fava P, Papini M, Bernengo MG. Flow cytometric analyses of circulating regulatory T cells in patients with dermatitis herpetiformis and other immune mediated dermatoses. GIORN ITAL DERMAT V 2013; 148:197-201. [PMID: 23588145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Regulatory T cells (Tregs) play a crucial role by maintaining the peripheral tolerance and inhibiting autoimmunity. In recent years, numerous autoimmune and immune-mediated diseases have been shown to present significant number depletion and/or function impairment of this subset. In the present study, we present a brief overview of the results obtained by our group in association with the centers belonging to the Italian Immunopathology Group, as to the expression levels and biological significance of circulating regulatory CD4+CD25+brightFOXP3+ T cells in a variety of immune-mediated skin diseases (such as psoriasis, scleroderma, bullous pemphigoid and GvHD), together with preliminary results achieved in patients with inflammatory bowel disease-related dermatoses. This review shows that this series of different cutaneous diseases characterised by an immune-mediated pathogenesis, share a significant down-regulation of circulating FOXP3+ Treg cells, whilst the treatment and the achievement of clinical response are generally associated with an opposite phenomenon with up-regulation of Treg cells. Future studies are mandatory to identify the effective role of these modifications in the disease pathogenesis as well as its relationship with the clinical response.
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Affiliation(s)
- P Quaglino
- Dermatologic Clinic, Department of Medical Sciences, University of Turin, Italy.
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Antiga E, Verdelli A, Calabrò A, Fabbri P, Caproni M. Clinical and immunopathological features of 159 patients with dermatitis herpetiformis: an Italian experience. GIORN ITAL DERMAT V 2013; 148:163-169. [PMID: 23588141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM The aim of this paper to report the main clinical and immunopathological findings of our case series of 159 patients with dermatitis herpetiformis (DH). METHODS All DH patients that were diagnosed from 1995 to 2012 at the Section of Dermatology of the University of Florence were included in the study. Clinical data were collected for each patient. Moreover, histopathological examination on both the skin and the small bowel, direct immunofluorescence on perilesional skin as well as the search for anti-endomysium and anti-tissue transglutaminsase antibodies (tTG) were performed. RESULTS A total of 159 patients with a male predominance were enrolled. About 36% of the patients were below the age of 20. The most frequent clinical features seen in our DH patients were represented by figurate erythema, wheals, papules and scratching lesions, while the knees, elbows and buttocks were the most commonly involved sites. All the 22 patients that underwent a bowel biopsy showed the typical alterations found in celiac disease. Moreover, 100% of the patients showed granular IgA deposits at the papillary tips. Finally, anti-endomysium and anti-tTG antibodies were present in 90% and 96% of the patients, respectively. CONCLUSION We reported one of the largest case series of patients with DH from a single center. Our study confirmed most of the data from the Literature, and in particular the association of DH to histologically proven CD in all the biopsied cases. Another interesting finding of our study is the high prevalence of DH within pediatric patients, that is usually underreported.
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Affiliation(s)
- E Antiga
- Section of Dermatology, Department of Surgery and Translational Medicine, University of Florence, Italy.
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Antiga E, Fabbri P, Caproni M. Is dermatitis herpetiformis changing? GIORN ITAL DERMAT V 2013; 148:159-162. [PMID: 23588140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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23
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Plotnikova N, Miller JL. Dermatitis herpetiformis. Skin Therapy Lett 2013; 18:1-3. [PMID: 23674144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Dermatitis herpetiformis (DH) is an autoimmune, pleiomorphic, papulovesicular disorder associated with celiac disease and gluten sensitivity. DH is characterized by subepidermal bullae on hematoxylin and eosin staining and granular immunoglobulin A deposits in the dermal papillae using the direct immunofluorescence method. Antibodies to tissue transglutaminase and epidermal transgulatminase can be measured serologically, although biopsy is still required for definitive diagnosis of DH. Gluten free diet (GFD) is the first-line therapeutic approach that can alleviate both cutaneous and intestinal manifestations of this condition, while dapsone and sulfones target the skin eruption only. Combined therapy with GFD and dapsone is an initial treatment of choice to control the cutaneous manifestations of DH. This article will provide a comprehensive review of DH, including its epidemiology, clinical and pathological findings, diagnostic evaluation, and management.
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Affiliation(s)
- Natalia Plotnikova
- Division of Dermatology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
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Davis JC, Wilson ML. The best diagnosis is: dermatitis herpetiformis. Cutis 2012; 90:221-231. [PMID: 23270187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Jon Clay Davis
- Southern Illinois University, Springfield, IL 62704, USA.
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25
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Zebrowska A, Wagrowska-Danilewicz M, Danilewicz M, Sokolowska M, Stasikowska-Kawecka O, Erkiert-Polguj A, Cynkier A, Pawliczak R, Sysa-Jedrzejowska A, Waszczykowska E. Does Adam17 cause the destruction of anchoring fibers via shedding tumor necrosis factor α in bullous pemphigoid and dermatitis herpetiformis? J Cutan Med Surg 2012; 16:149-50. [PMID: 22713436 DOI: 10.1177/120347541201600303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Ohata C, Ishii N, Hamada T, Shimomura Y, Niizeki H, Dainichi T, Furumura M, Tsuruta D, Hashimoto T. Distinct characteristics in Japanese dermatitis herpetiformis: a review of all 91 Japanese patients over the last 35 years. Clin Dev Immunol 2012; 2012:562168. [PMID: 22778765 PMCID: PMC3385876 DOI: 10.1155/2012/562168] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 03/22/2012] [Accepted: 03/29/2012] [Indexed: 12/19/2022]
Abstract
We reviewed all 91 Japanese dermatitis herpetiformis (DH) patients reported over the last 35 years. The male-to-female ratio was 2 : 1. The mean age at onset was 43.8, and 13 years earlier for female patients. More than half of these Japanese DH patients showed granular IgA deposition in the papillary dermis, and another one-third showed fibrillar IgA deposition. The male patients with granular IgA deposition were 10 years older than those with fibrillar deposition. Whereas patients with granular IgA deposition showed typical distribution of the skin lesions, the predilection sites of DH tended to be spared in patients with fibrillar IgA deposition. Only 3 patients had definite gluten-sensitive enteropathy. There was a statistical difference in the frequency of human leukocyte antigen (HLA)-DR9 between the granular group and controls among Japanese. No patients had HLA-DQ2 or -DQ8, which is frequently found in Caucasian DH patients. The absence of HLA-DQ2/DQ8, the inability to identify celiac disease in most cases, the predominance of fibrillar IgA, and the unusual distribution of clinical lesions in Japanese patients suggest that Japanese DH may be a subset of DH patients and have a pathogenesis which is different from that currently proposed in Caucasian DH patients.
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Affiliation(s)
- Chika Ohata
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Norito Ishii
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Takahiro Hamada
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Yutaka Shimomura
- Laboratory of Genetic Skin Diseases, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan
| | - Hironori Niizeki
- Department of Dermatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
| | - Teruki Dainichi
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Minao Furumura
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
| | - Takashi Hashimoto
- Department of Dermatology, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
- Kurume University Institute of Cutaneous Cell Biology, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan
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Lu Y, Zhang M. Pemphigus herpetiformis in a patient with well-differentiated cutaneous angiosarcoma: case report and review of the published work. J Dermatol 2011; 39:89-91. [PMID: 22007947 DOI: 10.1111/j.1346-8138.2011.01287.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Antiga E, Caproni M, Fabbri P. Comment on "Dermatitis herpetiformis sera or goat anti-transglutaminase-3 transferred to human skin-grafted mice mimics dermatitis herpetiformis immunopathology". J Immunol 2011; 187:595; author reply 595-6. [PMID: 21734078 DOI: 10.4049/jimmunol.1190031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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29
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Pallais JC, Mackool BT, Pitman MB. Case records of the Massachusetts General Hospital: Case 7-2011: a 52-year-old man with upper respiratory symptoms and low oxygen saturation levels. N Engl J Med 2011; 364:957-66. [PMID: 21388314 DOI: 10.1056/nejmcpc1013923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- J Carl Pallais
- Endocrinology Division, the Department of Medicine, Massachusetts General Hospital, Boston, USA
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30
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Korossy KS. Non-dermatitis herpetiformis gluten-sensitive dermatitis: a personal account of an unrecognized entity. Cutis 2010; 86:285-286. [PMID: 21284279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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31
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Zebrowska A, Wagrowska-Danilewicz M, Danilewicz M, Wodz K, Sokolowska M, Erkiert-Polguj A, Sysa-Jedrzejowska A, Waszczykowska E, Pawliczak R. Expression of selected ADAMs in bullous pemphigoid and dermatitis herpetiformis. J Dermatol Sci 2009; 56:58-61. [PMID: 19695840 DOI: 10.1016/j.jdermsci.2009.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 06/01/2009] [Accepted: 06/23/2009] [Indexed: 11/15/2022]
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Roth MM, Feier V, Cristodor P, Moguelet P. Impetigo herpetiformis with postpartum flare-up: a case report. Acta Dermatovenerol Alp Pannonica Adriat 2009; 18:77-82. [PMID: 19588063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Impetigo herpetiformis is a rare dermatosis of pregnancy with typical onset during the last trimester of pregnancy and rapid resolution during the postpartum period. It is still a matter of debate whether it is a variant of pustular psoriasis or a separate entity. We report a case of impetigo herpetiformis with an earlier onset during the second trimester of pregnancy (G4 P2) and an atypical postpartum flare-up. Even though the case is not new per se, it reveals the natural course of this rare disease because the condition was neglected and given no oral treatment throughout the entire pregnancy. Consequently, the patient had a premature delivery with premature rupture of membranes, placental insufficiency, and intrauterine growth retardation.
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Affiliation(s)
- M-M Roth
- Dermato-venerology Clinic, 5 Marasesti, 300086 Timisoara, Romania.
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33
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Zebrowska A, Waszczykowska E, Wagrowska-Danilewicz M, Danilewicz M, Erkiert-Polguj A, Pawliczak R, Sysa-Jedrzejowska A. Expression of selected adhesion molecules in dermatitis herpetiformis and bullous pemphigoid. POL J PATHOL 2009; 60:26-34. [PMID: 19670701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Dermatitis herpetiformis (DH) and bullous pemphigoid (BP) are autoimmune diseases characterized by destruction of the basement membrane zone (BMZ) and anchoring fibres by autoantibodies and infiltration. Adhesion molecules can take part in these phenomena. Skin biopsies were taken from 13 patients with DH, 21 with BP, and from 10 healthy subjects. The localization and expression of E and L selectins and beta1, beta3, beta4 integrins were studied by immunohistochemistry. Expression of selectins was detected mainly in the skin leukocytes in all samples. Expression of beta1, beta3 integrins was detected mainly in basal keratinocytes. Expression of beta 4 integrin was irregular and detected mainly in the blister. Our results suggest that integrins and selectins may play an important role in the destruction of BMZ in DH and BP. The elucidation of the role of adhesion molecules in the pathogenesis of bullous diseases may be helpful in the development of new targeted therapies.
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Affiliation(s)
- Agnieszka Zebrowska
- Department of Dermatology and Venereology, Medical University of Lodz, Lodz.
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Guerriero C, Lanza Silveri S, Sisto T, Rosati D, De Simone C, Fossati B, Pomini F, Rotoli M, Amerio P, Capizzi R. Impetigo herpetiformis occurring during N-butyl-scopolammonium bromide therapy in pregnancy: case report. J BIOL REG HOMEOS AG 2008; 22:141-144. [PMID: 18597707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Impetigo herpetiformis (IH) is a rare dermatosis arising during the third trimester of pregnancy which is generally considered as a form of pustular psoriasis of unknown aetiology. Clinically it is characterized by erythematous plaques surrounded by sterile pustules associated with fever, diarrhea, sweating and increasing risk of stillbirth for placental insufficiency. We describe a case of developed erythematous plaques surrounded by pustules localised initially to the trunk of a 35-year-old woman at the 34th week of gestation after 5 days of treatment with N-Butyl-Scopolammonium, and which later involved the upper and lower limbs. Skin histology confirmed the diagnosis of generalised pregnancy pustular psoriasis (impetigo herpetiformis). IH is reported to be associated with hypocalcemia, hypoparathyroidism, use of oral contraceptives and bacterial infections. This is the first report suggesting the potential role of drugs other than oral contraceptives in the pathogenetic mechanism of this disease. In this case an adverse cutaneous reaction to BB could be the cause of the development of Koebner isomorphism.
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36
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Marietta EV, Camilleri MJ, Castro LA, Krause PK, Pittelkow MR, Murray JA. Transglutaminase Autoantibodies in Dermatitis Herpetiformis and Celiac Sprue. J Invest Dermatol 2008; 128:332-5. [PMID: 17762854 DOI: 10.1038/sj.jid.5701041] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Dermatitis herpetiformis (DH) is an autoimmune blistering skin disorder that is associated with intestinal gluten sensitivity. Epidermal transglutaminase (TGe) and closely related tissue transglutaminase (tTG) are considered to be autoantigens in DH, because a majority of DH patients have IgA specific for TGe and for tTG. It is unknown where and how these autoantigen-specific IgAs are generated in DH. Results reported in this paper on nine DH patients on a gluten containing diet demonstrate that the levels of circulating anti-tTG IgA and anti-TGe IgA in DH are correlated with each other and that both appear to be correlated with the degree (extent) of enteropathy. An analysis of 15 untreated celiac sprue (CS) patients demonstrated that approximately 33% of CS patients had elevated levels of anti-TGe IgA. These results would indicate that intestinal damage is associated with the production of anti-tTG IgA and anti-TGe IgA in DH patients.
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Affiliation(s)
- Eric V Marietta
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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37
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Van L, Browning JC, Krishnan RS, Kenner-Bell BM, Hsu S. Dermatitis herpetiformis: potential for confusion with linear IgA bullous dermatosis on direct immunofluorescence. Dermatol Online J 2008; 14:21. [PMID: 18319038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
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Abstract
BACKGROUND Dermatitis herpetiformis (DH) is a cutaneous manifestation of gluten sensitivity, occasionally associated with other autoimmune disorders, and reportedly associated with an increased risk of lymphoproliferative disorders. We describe a series of patients with DH, focusing on associated disorders (particularly celiac disease), incidence of lymphoma, histopathology, and sensitivity of direct immunofluorescence (DIF) testing and serologic testing with antiendomysium antibodies for the diagnosis of DH. METHODS The medical records of 264 patients with DH diagnosed between 1970 and 1996 were reviewed retrospectively. In addition, the records of six patients evaluated before the advent of DIF testing between 1932 and 1969 were reviewed. RESULTS Established celiac disease was present in 12.6% of patients with DH, autoimmune systemic disorders in 22.2%, malignant neoplasms in 10.4%, sarcoidosis in four patients, and ulcerative colitis in six patients. Lymphoproliferative disorders were found in seven patients. The histopathologic examinations showed a marked predominance of neutrophils in the inflammatory infiltrate. DIF testing was positive in 92.4% of the patients tested. Indirect immunofluorescence assay indicated circulating antiendomysial antibodies in the sera of 40 of the 63 patients tested (63.5%). CONCLUSIONS In this large series of patients with DH from a single institution, patients had a low incidence of symptomatic gluten-sensitive enteropathy, low risk of lymphoproliferative disorders, and associations with other systemic autoimmune disorders. The value of DIF testing in the diagnosis of DH was confirmed. The detection of antiendomysial antibodies by indirect immunofluorescence was less sensitive than indicated by other reports.
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Abstract
Dermatitis herpetiformis (DH) is a rare immunobullous disorder of the skin that is associated with gluten hypersensitivity. Subepidermal IgA-type antibody deposition against tissue transglutaminase leads to dense neutrophilic microabscess and eventually into vesicles in dermal papillae, which may occasionally merge into bullae. Being a subepidermal vesiculobullous disorder, DH is frequently associated with postinflammatory pigmentary changes, particularly hypopigmentation. However, the association of DH with true vitiligo is extremely rare. Here, we report a 21-year-old male with vitiligo and comorbid DH, and review the literature. This new case had severely pruritic, papular and papulovesicular lesions that were localized symmetrically and partly confined to the pre-existing vitiliginous areas. The skin biopsy specimen taken from an erythematous papule on the elbow showed characteristic findings of DH and vitiligo. Direct immunofluorescence microscopy of the perilesional skin revealed granular IgA deposition of dermal papillae. There are only 10 reports in the literature of DH and vitiligo comorbidity.
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Affiliation(s)
- Ozlem Karabudak
- Department of Dermatology, GATA Teaching Hospital, Istanbul, Turkey.
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40
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Inchara YK, Rajalakshmi T. Direct immunofluorescence in cutaneous vesiculobullous lesions. INDIAN J PATHOL MICR 2007; 50:730-732. [PMID: 18306538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
UNLABELLED Direct Immunofluorescence (DIF) is invaluable in the diagnosis of cutaneous vesiculobullous lesions (VBL). It is limited by technical factors and disease nature. 1) To record the sensitivity of DIF in VBL 2) To correlate DIF with clinical, histologic findings and analyse discrepancies. MATERIAL AND METHODS A retrospective study of 100 DIFs on suspected VBL of skin. DIF, histology and clinical data were reviewed. 73/100 cases showed DIF patterns concordant with clinical/histologic diagnosis. The sensitivity of DIF was 88% in Pemphigus group (39/ 44), 82% in Bullous Pemphigoid (BP) (23/28), and 20% in Dermatitis Herpetiformis (DH) (1/5).18 cases of histologically proven VBL were negative and of these, 4 had no epidermis. The remaining 9 cases were discordant with clinical/histologic features, including 4 BP and 5 DH, whose histology was non-specific and will be discussed in detail. One case of DH showed an aberrant vasculitic pattern. DIF is of great value in the diagnosis of VBL, specially in clinical/histologic dilemmas. In DH, neither biopsy nor DIF were very useful and response to therapy was the standard. Sampling errors contributed to false negative results. Proper selection of cases and judicious use are mandatory to optimize its' utility.
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Affiliation(s)
- Y K Inchara
- Department of Pathology, St. John's Medical College, Bangalore
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Abstract
Autoimmune bullous diseases are associated with autoimmunity against structural components maintaining cell-cell and cell matrix adhesion in the skin and mucous membranes. Pemphigus diseases are characterized by autoantibodies against the intercellular junctions and intraepithelial blisters. In pemphigoid diseases and epidermolysis bullosa acquisita, sub-epidermal blistering is associated with autoantibodies targeting proteins of the hemidesmosomal anchoring complex. The autoantigens in autoimmune blistering diseases have been extensively characterized over the past three decades. In general, the pathogenicity of autoantibodies, already suggested by clinical observations, has been conclusively demonstrated experimentally. Detection of tissue-bound and circulating serum autoantibodies and characterization of their molecular specificity is mandatory for the diagnosis of autoimmune blistering diseases. For this purpose, various immunofluorescence methods as well as immunoassays, including immunoblotting, enzyme-linked immunosorbent assay and immunoprecipitation have been developed. This review article describes the immunopathological features of autoimmune bullous diseases and the immunological and molecular tests used for their diagnosis and monitoring.
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Affiliation(s)
- Sidonia Mihai
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Cassian Sitaru
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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42
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Donaldson MR, Zone JJ, Schmidt LA, Taylor TB, Neuhausen SL, Hull CM, Meyer LJ. Epidermal Transglutaminase Deposits in Perilesional and Uninvolved Skin in Patients with Dermatitis Herpetiformis. J Invest Dermatol 2007; 127:1268-71. [PMID: 17205060 DOI: 10.1038/sj.jid.5700682] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Celiac disease is a genetically determined bowel disease also influenced by exogenous factors in which exposure to grain components triggers a chronic immune response with intestinal symptoms. Dermatitis herpetiformis represents the cutaneous manifestation of celiac disease. While intense pruritus is the characteristic symptom, clinical signs can be highly variable, ranging from grouped papulovesicles with excoriations or eczema-like lesions to minimal variants of discrete erythema and digital purpura. Diagnosis depends on direct fluorescence studies of perilesional skin displaying granular IgA deposits in dermal papillae. Suspecting and then searching for dermatitis herpetiformis is often clinically challenging, as the disease is a true chameleon with many clinical faces. Dapsone therapy alleviates the cutaneous symptoms and signs, but does not prevent the systemic complications of celiac disease; thus, strict adherence to a gluten-free diet is strongly advisable.
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Affiliation(s)
- C Pfeiffer
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Abuzakouk M, Barnes L, O'Gorman N, O'Grady A, Mohamed B, McKenna MJ, Freaney R, Feighery C. Dermatitis herpetiformis: no evidence of bone disease despite evidence of enteropathy. Dig Dis Sci 2007; 52:659-64. [PMID: 17253133 DOI: 10.1007/s10620-006-9576-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Accepted: 08/16/2006] [Indexed: 12/09/2022]
Abstract
The majority of patients with dermatitis herpetiformis (DH) have small intestinal enteropathy that may result in bone loss. The objective of this study was to evaluate bone mineral density (BMD) in DH and to examine whether dietary treatment or degree of the small intestinal lesion correlate with BMD. Twenty-five patients with DH (18 men) were investigated. Detailed dietary assessment and duodenal biopsies were performed on all patients before entry into the study. BMD at lumbar spine and femur was determined by DXA scan. Bone biomarkers, vitamin D, and parathyroid status were assessed. Twenty patients had enteropathy. None of the patients had hypovitaminosis D or secondary hyperparathyroidism. Resorption and formation markers were within normal limits. BMD Z-scores were not significantly different from expected (-0.38; CI, -0.84 to 0.07) and femur (0.46; CI, -0.06 to 0.97). There was no relationship between BMD Z-scores and the severity of the degree of enteropathy. We conclude that enteropathy of differing severity is present in 80% of patients with DH, but this is not associated with bone disease.
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Affiliation(s)
- M Abuzakouk
- Department of Immunology, CPL, St. James's Hospital, Dublin, 8 Ireland.
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Chmurova N, Parnicka Z, Svecova D, Manova A, Simaljakova M. Dermatitis herpetiformis in siblings. BRATISL MED J 2007; 108:519-521. [PMID: 18309643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Two Caucasian sisters, XZ and YZ, suffered from DH. However, the clinical course of their diseases was different; patient XZ, contrary to her sister YZ, suffered besides dermatitis herpetiformis (DH) also from coeliac disease (CD) and an autoimmune thyroid disease. The sisters were ordered to adhere to gluten-free diet and dapsone was prescribed, however, patient XZ developed a hypersensitivity to dapsone. The HLA typing disclosed that they were homozygous and that they shared HLA alleles DQB1*0201. Our results confirm the known association of DH to other autoimmune disorders and its well established association the HLA-DQB1*0201 allele. Although DH is generally not regarded as a familial disease our case report suggests its familial character (Fig. 3, Ref. 10). Full Text (Free, PDF) www.bmj.sk.
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Affiliation(s)
- N Chmurova
- Department of Dermatovenerology, Faculty of Medicine, Comenius University, Mickiewiczova 13, SK-813 69 Bratislava 1, Slovakia.
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Zebrowska A, Narbutt J, Sysa-Jedrzejowska A, Kobos J, Waszczykowska E. The imbalance between metalloproteinases and their tissue inhibitors is involved in the pathogenesis of dermatitis herpetiformis. Mediators Inflamm 2006; 2005:373-9. [PMID: 16489258 PMCID: PMC1533900 DOI: 10.1155/mi.2005.373] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Dermatitis herpetiformis (DH) is a subepidermal autoimmune
disease characterized by skin and intestinal lesions consistent
with coeliac disease. There are also some data that
metalloproteinases (MMPs) are involved in the development of skin
lesions in DH, however their exact role in this process is not
fully understood. The aim of the study was to investigate whether
MMPs and their inhibitors are involved in pathogenesis of DH. Skin
biopsies were taken from 13 patients with active DH and from 10
healthy subjects. The localization and expression of MMPs and
TIMPs were examined by immunohistochemistry. MMPs expression was
detected in basal keratinocytes and in the whole epidermis in all
of the DH subjects. Neutrophils in microabscesses and in blister fluid
were also positive for MMPs. Expression of TIMPs was moderate or
weak in all examined biopsies. Our results allow us to conclude
that imbalance between these enzymes takes an important role in
the pathogenesis of DH.
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Affiliation(s)
- Agnieszka Zebrowska
- Department of Dermatology and Venereology, Medical University of Lodz, Poland.
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Sugai E, Smecuol E, Niveloni S, Vázquez H, Label M, Mazure R, Czech A, Kogan Z, Mauriño E, Bai JC. Celiac disease serology in dermatitis herpetiformis. Which is the best option for detecting gluten sensitivity? Acta Gastroenterol Latinoam 2006; 36:197-201. [PMID: 17225447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Dermatitis herpetiformis (DH), a well-established gluten-sensitive skin disorder presenting variable degrees of enteropathy, constitutes a very useful model in order to assess the utility of the celiac disease (CD)-related serology in patients with mild intestinal damage. OBJECTIVE Our aim was to explore comparatively the performance of a panel of CD-related serologic tests in patients with DH. METHODS We assessed a series of 18 consecutive patients with skin biopsy proven DH presenting the overall spectrum of intestinal damage ranging from normal mucosa (n = 6) to total villous atrophy (TVA) (n = 6) through partial villous atrophy (PVA) (n = 6). Sera were obtained from all patients while consuming a gluten containing diet. Serologic tests were antiendomysial, anti-tissue transglutaminase and antigliadin antibodies, and newly developed tests detecting both antibody isotypes (IgA and IgG) against deamidated synthetic gliadin-derived peptides (a-GDP). RESULTS Serologic tests had a variable behaviour depending on the degree of enteropathy. While the majority of tests detected patients with TVA, only 50% of those with normal histology had positive assays. Patients with PVA had discordant results. Classical CD-specific tests were positive in only some patients with mild damage while all of them were identifed by a single assay detecting both isotypes of a-GDR CONCLUSION: The detection of a-GDP antibodies was the most reliable tool in order to identify gluten sensitivity in DH patients presenting a wide range of intestinal damage. Further studies should explore if these findings can be extrapolated to patients with CD having mild enteropathy.
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Affiliation(s)
- Emilia Sugai
- Small Bowel Section, Department of Medicine, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo", Buenos Aires, Argentina
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Affiliation(s)
- E Bathelier
- Service de Dermatopathologie, Hôpital de l'Hôtel-Dieu, 1, place de l'Hôpital, 69288 Lyon Cedex 02
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Mohamed BM, Feighery C, Kelly J, Coates C, O'Shea U, Barnes L, Abuzakouk M. Increased protein expression of matrix metalloproteinases -1, -3, and -9 and TIMP-1 in patients with gluten-sensitive enteropathy. Dig Dis Sci 2006; 51:1862-8. [PMID: 16964549 DOI: 10.1007/s10620-005-9038-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Accepted: 09/07/2005] [Indexed: 12/25/2022]
Abstract
Gluten-sensitive enteropathy is characterized by small intestinal damage. The pathogenic mechanisms involved are not precisely understood. There is recent interest in the possibility that matrix metalloproteinases might play a pathogenic role. Using immunohistochemistry technique, we examined the protein expression of matrix metalloproteinases-1, -3, and -9 and the tissue inhibitor metalloproteinase-1 in duodenal biopsies from 30 patients with celiac disease and dermatitis herpetiformis. We demonstrated that the percentage of cells expressing these enzymes and their inhibitor in all patients was significantly greater than in the normal controls (P < 0.0001). This was evident even in patients with a minimal lesion but was most marked in patients with severe damage, mirroring the degree of inflammation in the small intestinal tissue. The increased expression of these enzymes and their inhibitor in the duodenal mucosa of patients with gluten-sensitive enteropathy suggests a role for these enzymes in the tissue remodeling which is a feature of these disorders.
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Affiliation(s)
- Bashir M Mohamed
- Department of Immunology, St. James's Hospital, Trinity College and Dublin Molecular Medicine Center, Dublin, Ireland
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Saito M, Böer A, Ishiko A, Nishikawa T. Atypical dermatitis herpetiformis: a Japanese case that presented with initial lesions mimicking prurigo pigmentosa. Clin Exp Dermatol 2006; 31:290-1. [PMID: 16487118 DOI: 10.1111/j.1365-2230.2005.02009.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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