Medication Summary

Treatment consists of a gluten-free diet plus pharmacotherapeutic agents. Dapsone is indicated as a primary treatment for dermatitis herpetiformis. Sulfapyridine, a previous mainstay of therapy for dermatitis herpetiformis, is no longer available in most countries. However, sulfasalazine is partly metabolized to sulfapyridine. It may be considered for off-label use in dermatitis herpetiformis in patients who are unable to tolerate a high enough dose of dapsone.^[51]Corticosteroids may also be considered.

Case reports have described use of rituximab for recalcitrant dermatitis herpetiformis.^{[52, 58]}Cases have also been described using colchicine^[59]and tetracycline.^{[60, 61, 62]}

Class Summary

Dapsone is considered the treatment of choice. Other anti-inflammatory and immunomodulatory agents may be required if dapsone is insufficient or not tolerated.

Dapsone

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The precise mechanism by which dapsone works in dermatitis herpetiformis has not been established. It is a competitive antagonist of para-aminobenzoic acid (PABA) and prevents bacteria from using PABA for folic acid synthesis. It is indicated as a primary treatment for dermatitis herpetiformis.

Sulfasalazine (Azulfidine)

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Sulfasalazine elicits anti-inflammatory effects. It has a high affinity for distribution to connective tissues. Sulfasalazine is metabolized to 5-aminosalicylic acid and sulfapyridine.

Rituximab (Rituxan, Truxima)

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Rituximab is a humanized monoclonal antibody. It binds to CD20 antigen, inducing complement- or antibody-mediated cytolysis.

Colchicine (Colcrys, Gloperba, Mitigare)

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Colchicine elicits various effects on neutrophil migration, degranulation, and activation that may diminish inflammation.

Tetracycline

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The mechanism by which tetracycline may act for use in dermatitis herpetiformis is not established.

Class Summary

Systemic corticosteroids may be considered.

Prednisone (Deltasone)

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Prednisone is a glucocorticosteroid that elicits mild mineralocorticoid activity and moderate anti-inflammatory effects. It controls or prevents inflammation by controlling the rate of protein synthesis, suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at cellular level.

Questions

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Media Gallery

Light micrograph shows neutrophils in the dermal papillae, with fibrin deposition, neutrophil fragments, and edema (hematoxylin and eosin stain).
Papillary microabscesses form and progress to subepidermal vacuolization and vesicle formation in the lamina lucida, the weakest portion of the dermoepidermal junction (hematoxylin and eosin stain).
Classic vesicles of dermatitis herpetiformis.
Immunofluorescence showing immunoglobulin A at the dermoepidermal junction (direct immunofluorescence stain).
Polymorphic lesions on extensor surface of arm.

of 5

Author

Jami L Miller, MD Associate Professor, Department of Dermatology, Vanderbilt University Medical School; Vice Chair for Education, Director of Phototherapy Unit, Medical Director of Dermatology Clinic at 100 Oaks, Vanderbilt University Medical Center

Jami L Miller, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Shehnaz Aysha K Zaman, MD Resident Physician, Department of Dermatology, Vanderbilt Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Julia R Nunley, MD Professor, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, Women's Dermatologic Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Board of Dermatology<br/>Author for: Up-to-date.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Russell Hall, MD J Lamar Callaway Professor And Chair, Department of Dermatology, Duke University Medical Center, Duke University School of Medicine

Russell Hall, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, American Society for Clinical Investigation, Society for Investigative Dermatology

Disclosure: Received consulting fee from Novan for consulting; Received consulting fee from Stieffel, a GSK company for consulting; Received salary from Society for Investigative Dermatology for board membership.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Kristina Collins, MD, and Hunter Sams, MD, to the development and writing of this article.

Dermatitis Herpetiformis Medication

Medication Summary

Anti-inflammatory and Immunomodulatory Agents