A case of dermatitis herpetiformis after a mini-gastric bypass surgery
Authors: Farid Stephan, Roger Haber, Diane Maalouf, Roland Tomb
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Celiac disease and dermatitis herpetiformis share the same strong HLA association, the presence of circulating IgA antitissue and antiepidermal transglutaminase antibodies, and the same typical histologic features of villous atrophy of the small intestine.1Bolotin D. Petronic-Rosic V. Dermatitis herpetiformis, part I: epidemiology, pathogenesis, and clinical presentation.J Am Acad Dermatol. 2011; 64: 1017-1024Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar Both diseases can be triggered by gluten overload and gastric surgery.2Bai J. Moran C. Martinez C. Niveloni S. Crosetti E. Sambuelli A. et al.Celiac sprue after surgery of the upper gastrointestinal tract: report of 10 patients with special attention to diagnosis, clinical behavior, and follow-up.J Clin Gastroenterol. 1991; 13: 521-524Crossref PubMed Scopus (28) Google Scholar We report a case of dermatitis herpetiformis after mini-gastric bypass surgery with no clinical sign or symptom of celiac disease. Mini-gastric bypass is a modification of the standard Roux-en-Y procedure using a long gastric tube with an antecolic loop gastrojejunostomy. It has become a widely performed bariatric surgery because it offers similar efficacy with a simpler technique and a lower rate of complicatons.3Lee W.J. Yu P.J. Wang W. Chen T.C. Wei P.L. Huang M.T. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial.Ann Surg. 2005; 242: 20-28Crossref PubMed Scopus (344) Google Scholar A 40-year-old white woman presented for a 1-year history of intermittent itching with symmetrically grouped papulovesicles on the extensor surfaces of the elbows, the shoulders, and the buttocks, with excoriations and hyperpigmentation (Fig 1). She was treated with 0.05% fluocinonide cream with no improvement. Two years before this rash, she had a mini-gastric bypass for morbid obesity. She had no significant medical history and no symptom or sign of celiac disease before or after the surgery. A hematoxylin-eosin stain showed subepidermal bullae and clefts in dermal papillae filled with neutrophils and a perivascular mononuclear infiltrate with neutrophils. Direct immunofluorescence studies showed granular IgA deposits in the dermal papillae (Fig 2). Endomysial and transglutaminase antibodies, both IgG and IgM, were positive. All other blood tests were within normal limits. The patient was started on a gluten-free diet and dapsone (100 mg daily) with clinical improvement of her symptoms within a few days. Bai et al2Bai J. Moran C. Martinez C. Niveloni S. Crosetti E. Sambuelli A. et al.Celiac sprue after surgery of the upper gastrointestinal tract: report of 10 patients with special attention to diagnosis, clinical behavior, and follow-up.J Clin Gastroenterol. 1991; 13: 521-524Crossref PubMed Scopus (28) Google Scholar reported 10 patients who developed symptoms of celiac disease 2 months after different types of peptic ulcer surgery. Kovaleski et al4Kovaleski C. Jaliman D. Kumar V. Valeski J.E. Dermatitis herpetiformis following gastric surgery.Arch Dermatol. 1997; 133: 113-114PubMed Google Scholar described a patient who developed dermatitis herpetiformis after a gastric stapling procedure and a second who developed dermatitis herpetiformis after a gastrectomy with partial pancreatectomy and colectomy. It is known that dermatitis herpetiformis is linked to gluten intolerance and has a clear relationship to celiac disease but the development of dermatitis herpetiformis without celiac disease is not unexpected because the pathogenesis behind the skin and the intestinal lesions are unlikely to be fully identical. About 5% of celiac disease cases develop dermatitis herpetiformis5Rose C. Brocker E.B. Zillikens D. Clinical, histological and immunopathological findings in 32 patients with dermatitis herpetiformis Duhring.J Dtsch Dermatol Ges. 2010; 8: 265-271Crossref PubMed Google Scholar and the histologic intestinal changes persist even when cutaneous symptoms are controlled with dapsone but normalize with strict avoidance of gluten. Patients with isolated celiac disease do not have cutaneous IgA deposition,6Karlsson I.J. Dahl M.G. Marks J.M. Absence of cutaneous IgA in coeliac disease without dermatitis herpetiformis.Br J Dermatol. 1978; 99: 621-625Crossref PubMed Scopus (14) Google Scholar showing that this phenomenon is related to dermatitis herpetiformis itself. As suggested by Kovaleski et al,4Kovaleski C. Jaliman D. Kumar V. Valeski J.E. Dermatitis herpetiformis following gastric surgery.Arch Dermatol. 1997; 133: 113-114PubMed Google Scholar the triggering factor of dermatitis herpetiformis is probably the surgery-induced enteral inflammation leading to a cross-reaction between cutaneous and intestinal antitransglutaminase antibodies. These antibodies of mucosal origin can persist in circulation and deposit in the skin. In conclusion, dermatitis herpetiformis is a model of autoimmune disease linking gastrointestinal mucosal inflammation to cutaneous condition. The exact mechanism by which gastrointestinal inflammation translates into cutaneous disease is unknown. Dermatitis herpetiformis should be suspected in any pruritic rash after mini-gastric bypass and other surgeries of the upper gastrointestinal tract.