Dermatitis herpetiformis
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225778518
2008-07-15T10:36:38Z
SmackBot
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Date the maintenance tags or general fixes
{{Merge|Coeliac disease|date=November 2007}}
{{Unreferenced|date=July 2008}}
{{Infobox_Disease |
Name = Dermatitis herpetiformis |
Image = |
Caption = |
DiseasesDB = 3597 |
ICD10 = {{ICD10|L|12|2|l|10}}, {{ICD10|L|13||l|10}} |
ICD9 = {{ICD9|694.0}} |
ICDO = |
OMIM = |
MedlinePlus = 001480 |
eMedicineSubj = derm |
eMedicineTopic = 95 |
MeshID = |
}}
'''Dermatitis herpetiformis''' ('''DH'''), or '''Duhring's Disease''', is a [[skin]] disorder often associated with [[coeliac disease]]. It is a chronic, extremely itchy rash consisting of [[papule]]s and [[Vesicle (Biology)|vesicles]]. Dermatitis herpetiformis is associated with sensitivity of the intestine to gluten in the diet (celiac sprue). Despite its name, it does not result from infection with [[herpesvirus]].
Dermatitis herpetiformis usually begins in the twenties, though children may sometimes be affected. It is seen in both men and women. Though the cause of the rash is unknown, dermatitis herpetiformis is frequently associated with [[gluten]] (a protein found in cereals) sensitivity in the small bowel.
== Symptoms ==
{{Gluten sensitivity}}
Dermatitis herpetiformis breakouts are usually extremely itchy. In many people the [[Vesicle (Biology)|vesicles]] or [[papule]]s appear on the elbows, knees, back, and buttocks (pressure points). It may also present as a patch of red skin with little water blisters scattered about. It is a systemic condition; the unpredictable skin rash may appear or be exacerbated by any irritation such as dry skin, scratching or clothing that is rough or scratchy. The fact that the rash is most prevalent at pressure points (where clothing rubs the most) may be why the symptoms sometimes appear to be symmetrical.
== Signs and tests ==
A skin [[biopsy]] and direct [[immunofluorescence]] test of the skin are performed in most cases; doctors may additionally recommend a biopsy of the intestines.
There are deposits of Immunoglobulin A at the apex of the dermal papillae which can be detected by immunoflourescence.{{Fact|date=July 2008}}
== Treatment ==
[[Dapsone]], an antibiotic, may help the majority of patients.
A strict [[gluten-free diet]] will also be recommended to help control the disease. Adherence to this diet may eliminate the need for medications and prevent later complications.
== Dietary impact ==
{{Essay-like|date=December 2007}}
Dermatitis herpetiformis is a life-long disease. To avoid serious health consequences, a gluten-free diet should be adhered to. Such a diet can be difficult and socially troublesome, especially in young patients. Relapses and complications can result when dietary restrictions are not followed.
In the United States, dermatitis herpetiformis is less known among the population than in other countries. The widespread use of wheat byproducts in prepared food, soups and sauces makes dining problematic. However, certain restaurants (e.g., Japanese, Thai, Indian, and Latin American) offer a range of gluten-free menu options, and many major restaurant chains have responded to growing awareness of celiac disease (and by default dermatitis herpetiformis) by posting information about the gluten content of their menu items on their websites.
As knowledge of [[celiac disease]] has increased, availability and quality of gluten-free replacements for everyday food items (e.g., muffins, bagels, pasta) has continually improved. People with dermatitis herpetiformis and/or celiac disease can eat gluten-free foods. Awareness of the gluten problem, however, has increased the availability of traditional gluten products in the gluten-free form. For example, in the case of beer (which normally contains some gluten), many specialty brews have been developed around the world that may be described as [[gluten free beer]].
Unfortunately, a ramification of the dietary restrictions can be social isolation, as some people with Dermatitis herpetiformis become afraid of involvement in normal social life due to the trouble of these restrictions. Traveling, weddings, parties and other social events become difficult because the disease is a constant force that affects many aspects of an individual's perception of enjoyment and hassle. Coeliacs and sufferers of dermatitis herpetiformis may choose to withdraw from normal social activities. It is difficult to find activities where the issue of their disease does not surface. Thus, it is important for newly diagnosed with either dermatitis herpetiformis or celiacs to explain their needs to family and friends to maintain an active and healthy social life.
== Religious issues ==
'''The [[Eucharist]]''': The [[Christian]] sacrament of the Eucharist presents a unique challenge for Christian sufferers of dermatitis herpetiformis or coeliac disease.
In its classical form, the bread and/or communion wafers have traditionally contained wheat flour, and therefore gluten. Coeliacs and those with dermatitis herpetiformis are therefore presented with a choice between denying themselves a central part of their religious practice or placing themselves at risk of serious illness. In response to this, some makers of communion wafers have begun making gluten-free versions (usually made of rice), which are now widely available. Many churches permit (or have no official policy on) use of these wafers, while other churches do not allow them.
In particular, [[Roman Catholic Church|Roman Catholic]] doctrine requires that the Eucharistic host (the [[communion wafer]]) must contain at least some [[Leavening|unleavened]] wheat, as did the bread served at the [[Last Supper]]. The Catholic Church has approved the use of low-gluten wafers, but even these are not gluten-free. Some Catholic sufferers have requested permission to use rice wafers; these petitions have so far been denied.
However, official Roman Catholic doctrine is that a Catholic may validly receive communion by consuming a communion wafer and/or the consecrated wine. The [[Council of Trent]] decreed that taking either wine or wafer qualifies as a valid Communion:
"For we do not receive in the Sacred Host one part of [[Christ]] and in the Chalice the other, as though our reception of the totality depended upon our partaking of both forms; on the contrary, under the appearance of bread alone, as well as under the appearance of wine alone, we receive Christ whole and entire (cf. Council of Trent, Sess. XIII, can. iii). Therefore, any Catholic can receive the Eucharist in the 'fullness of the sacrament' (Catechism, Section 1390) simply in a sip of consecrated wine (even an approved low-[[alcohol]] wine); even those who cannot safely consume wheat (or indeed, any other grain) can safely partake of the Eucharist."
The matter has been controversial, however, and on August 22, 1994, the [[Congregation for the Doctrine of the Faith]] apparently banned those with coeliacs and dermatitis herpetiformis from the [[Priest#Catholic and Orthodox|priesthood]] stating, "Given the centrality of the celebration of the Eucharist in the life of the priest, candidates for the priesthood who are affected by celiac disease or suffer from [[alcoholism]] or similar conditions may not be admitted to [[Holy Orders|holy orders]]." After considerable upset and debate, the congregation softened the ruling on July 24, 2003 to "Given the centrality of the celebration of the Eucharist in the life of a priest, one must proceed with great caution before admitting to Holy Orders those candidates unable to ingest gluten or alcohol without serious harm,".
Eastern Orthodox Position: The [[Eastern Orthodox Church]] also requires that the bread used at the Eucharist be made with wheat flour; here the bread is [[Leavening|leavened]] with [[yeast]]. In the Orthodox practice, the consecrated bread and wine are given together from a chalice with a spoon. Some Orthodox sufferers have been able to receive communion simply by having the [[priest]] take only wine in the spoon; others, more sensitive to wheat, have had to have some of the wine set aside before the bread is added to the chalice. This latter case is extremely unusual, and is strictly speaking only permissible with the [[blessing]] of the diocesan [[bishop]]. While the Orthodox do not have such an explicit rationale as the Roman Catholic Church, their general understanding is that, in the case of exceptions made for the sake of [[Economy (Eastern Orthodoxy)|Economy]], the [[Holy Spirit]] makes up whatever is lacking.
Coeliacs, dermatitis herpetiformis, and [[Passover]] The Jewish festival of [[Pesach]] (Passover) may present problems with its obligation to eat matzo. [[Matzo]] is normally made from wheat or other gluten-containing grains. Oat matzo is now available, however. Many products prepared for Passover are not chametz, which means they are free of wheat, barley, spelt, oats, and rye. Potato starch is the primary starch used to replace the grains. These products make it easier to participate in Passover.
==Specialist breads, pastas, and beer ==
Although these diseases may tend to isolate individuals with the complaint, the situation is becoming less difficult year by year. Manufacturers are now making a wide range of very acceptable breads, and some pastas (notoriously horrible in the past) are virtually indistinguishable from "normal" pasta. Restaurants are beginning to offer gluten free menus and are recognising the size of the market that is largely not catered for. Coeliacs and those with dermatitis herpetiformis should not be afraid to ask establishments how they can cater for them. Where the question has been asked repeatedly, the proprietors tend to recognise the need, and become aware of the revenue that is lost where they do not provide a full range of products.
In many ways beer seems to be the hardest gluten free product to "get right". However, [[gluten-free beer]] is now available and there is now a range of ales, beers, and lagers to choose from. Around the world standards of "gluten free" vary. For example, while in the United Kingdom a beer with less than 20 parts per million gluten (20ppm) is "gluten free", in Australia it is not possible to describe any product as such if any gluten can be detected at all. Similarly, some "gluten free" breads can contain low levels of gluten in one country, in another they would contravene labelling or food standards legislation.
[[Image:Gluten free beer image.jpg|thumb|Gluten free beers]]
However, while large scale commercial beers are out of the question for those who cannot consume gluten<ref>{{cite web
| Carolyn Smagalski
| date= 2006
| url = http://www.bellaonline.com/articles/art40157.asp
| title = Ask the Beer Fox - Is Straub's Beer Gluten Free ?
| publisher = Carolyn Smagalski, Bella Online
}}
</ref>
<ref>
{{cite web
| Carolyn Smagalski
| date= 2006
| url = http://www.bellaonline.com/articles/art41529.asp
| title = Is Nigerian Guinness Gluten Free ?
| publisher = Carolyn Smagalski, Bella Online
}}
</ref>
<ref>
{{cite web
| Carolyn Smagalski
| date= 2006
| url = http://www.glutenfreebeerfestival.com/mainstream.html
| title = Ask the Beer Fox – Is Standard Lager Beer Safe for Coeliacs?
| publisher = Carolyn Smagalski, www.glutenfreebeerfestival.com
}}
</ref> (regardless of the sometimes misleading advice on some brewery websites), it is likely that most people with dermatitis herpetiformis coeliacs will be able to drink beer at under 20ppm (in moderation) without causing themselves any harm{{Fact|date=April 2007}}. It is important, however, for consumers of all "low gluten" foods and beverages to tell their consultant, and to ensure that even if the obvious symptoms are absent, there are no other negative effects continuing that they are unaware of.
However, the development of a range of gluten free beers is an example of those who cannot consume gluten "working together to socialize normally and avoid isolation caused by their special dietary needs. It also represents part of the return to a ‘normal’ life"<ref>
{{cite web
| Robert La France
| date= 2006
| url = http://www.glutenfreeda.com/may06_gf-beer.asp
| title = First-Ever Gluten-Free Beer Festival Quenches Celiacs’ Thirst
| publisher = Robert La France, Glutenfreeda.com
}}
</ref>.
== References ==
<references />
==See also==
*[[Gluten-free, casein-free diet]]
*[[Coeliacs]]
*[[Gluten free beer]]
*[[Gluten-free diet]]
== External links ==
* Pictures: [http://www.tidsskriftet.no/lts-img/2003/L03-22-Med-20-01.jpg ELBOW] [http://www.aafp.org/afp/980301ap/prue_f8.jpg ARMS]
* [http://www.triumphdining.com/ Gluten Free Restaurant Guide by Triumph Dining]
* [http://www.glutenfreebeerfestival.com/ glutenfreebeerfestival.com - a site that reviews gluten free beers]
* {{DermNet|immune/dermatitis-herpetiformis}}
{{Vesiculobullous disease}}
{{Diseases of the skin and subcutaneous tissue}}
[[Category:Skin diseases]]
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