Treatment and management of dermatitis herpetiformis

Abstract

The first documented use of sulfonamides for the treatment of dermatitis herpetiformis (DH) was by Costello in 1940 (1). He recorded that the rash of DH cleared within days of starting treatment with sulfapyridine. The rationale for this that DH was caused by bacterial allergy was subsequently proved erroneous. Nevertheless, the observation allowed for empiric treatment of the rash with drugs that are still used today though the mechanism of their therapeutic action remains unclear. The use of dapsone (diaminodiphenyl sulfone) for the management of DH was reported first by Esteves and Brando (2). Since these early observations, the use of these drugs for the treatment of DH has become well established, and their effectiveness is such that the therapeutic response to dapsone was used as a diagnostic test for the disease until the advent of immunofluorescence in the early 1970s. The next milestone in the therapy and management of DH came in 1966 when Marks and her colleagues demonstrated an enteropathy in 9 of 12 patients with DH (3). In the following year, Fry and colleagues pointed out the similarity between the enteropathy found in patients with DH and that of celiac disease (4). Further studies by these authors showed that both the enteropathy and the rash were gluten dependent, thereby indicating that DH was caused by an extrinsic antigen and was distinct from other bullous diseases (5,6). The efficacy of a gluten-free diet (GFD) has now been established by other centers (710) but it must be adhered to strictly to be effective and even then it takes an average of 28 months for the rash to be controlled by diet alone.