Overview

Are you or someone you know suffering from intestinal issues? Are you wanting to know more about digestive issues and their side effects? In this article, we will tackle coeliac disease and dermatitis herpetiformis.

So, let us start with what each of these two means. Coeliac is a common intestinal disorder that is driven by the immune system when ingesting gluten from food. ¹ It can give rise to different symptoms like stomach pain and constipation and sometimes manifest in a skin condition known as dermatitis herpetiformis (DH).¹

What is DH? It is a recurring skin condition that is characterised by very itchy skin that can cause lesions and blisters mostly seen on the elbows, knees, and buttocks.^2,3 

To further delve into this topic, the sections below will highlight the details of each disease. 

Coeliac disease

Overview

Coeliac disease is classified as an autoimmune disease that occurs in genetically predisposed individuals when they eat gluten.⁴ Gluten is a protein (found in wheat, barley and rye) that, once ingested, can lead to small intestine damage.⁴ So, when someone who is susceptible to this disease eats gluten, their immune system drives a response to attack the intestinal villi, which are small finger-shaped projections that line up the small intestines.⁴ Once these villi are damaged, the affected individual can not absorb nutrients properly into their bodies.⁴

As mentioned previously, coeliac has genetic factors, so it is hereditary, and it runs in families; people who have a first-degree relative (like their parents, siblings) with this illness have a 1 in 10 risk of developing it.⁴

Symptoms

There are multiple symptoms associated with coeliac disease, including:⁵

• Stomach-ache
• Bloating and farting
• Indigestion
• Constipation
• Vomiting
• Fatigue
• Weight loss (unexpected)
• Itchy rash (also known as dermatitis herpetiformis)
• Infertility
• Numbness and tingling in hands and feet
• Ataxia

If coeliac is left untreated, it can lead to:⁴

• Malnutrition
• Early onset of osteoporosis or osteopenia
• Heart disease
• Gallbladder malfunction
• Infertilities and miscarriages
• Iron deficiency anaemia
• Lactose intolerance
• Liver failure
• Pancreatic insufficiency
• Small intestine cancer and non-Hodgkin lymphoma
• Neurological manifestations like ADHD, headaches, seizures, dementia, neuropathy, myopathy, and multifocal leukoencephalopathy

Additionally, there is a risk of developing other autoimmune disorders in later stages of life. Early detection of coeliac can reduce chances of developing other conditions; for example, diagnosis at the ages of 2-4 can have a 10.4% chance of developing other autoimmune diseases, and this risk increases with age.⁴ If the diagnosis is done at 4–12 years of age, the risk increases to 16.7%. ⁴ If the diagnosis is not confirmed until 12-20 years of age, the risk will further increase to 27%, and diagnosis past 20 years of age will increase to 34%.⁴

Diagnosis

Testing for coeliac disease includes both blood tests and biopsy of the small intestines.⁶ Blood tests will include testing for antibodies that are present in the blood of patients that have coeliac; hence, gluten should remain in the diet when a blood test is done to avoid inaccurate results.⁶

If the results are positive, the healthcare provider will refer you to a specialist for stomach and bowel conditions (e.g., a gastroenterologist) that will perform further tests or a biopsy of the intestines to confirm the results.⁶ However, sometimes blood tests can be negative and require more tests, like biopsy.⁶

A biopsy is done in hospitals by a professional, and it can help confirm coeliac disease.⁶ It is done by putting an endoscope into the mouth and going down to the small intestines, where a sample will be taken and checked under the microscope.⁶

Treatment

Treatment of coeliac disease includes removal of gluten from the diet for life, as symptoms will return upon the introduction of gluten back into the diet.⁷ Additionally, there will be check ups performed by the healthcare provider and nutritional support and supplements to help you go through proper recovery.⁷

Gluten is not essential in the diet and can be replaced by other foods.⁷ Additionally, there are multiple alternatives nowadays that are gluten-free versions of common foods like pasta, pizza, and bread in supermarkets as well as health shops.⁷ There are other foods that can be consumed that do not have gluten naturally, like:⁷

• Most dairy products
• Fruits and vegetables
• Oats
• Meat and fish
• Potatoes
• Rice and rice noodles
• Gluten-free flours like rice, corn, soy and potato flour

Some foods to avoid that contain gluten include:⁷

• Bread
• Pasta
• Cereals
• Biscuits
• Cakes and pastries
• Pies
• Gravies and sauces

Dermatitis herpetiformis

Overview

Dermatitis herpetiformis, referred to as DH and Duhring’s disease, is a chronic skin condition that is a response to the ingestion of gluten.⁴ DH is rare and is found to be higher in European descent but is rare in Asian populations and even more rare in African American.³

Dermatitis herpetiformis is a complex disease and is similar in its pathogenesis to coeliac disease.³ It is considered an autoimmune illness, where antibody IgA reacts in the skin against epidermal transglutaminase (TG3) upon gluten ingestion, as well as the presence of circulating autoantibodies against tissue transglutaminase (TG2) and TG3.^2,4 Additionally, the presence of certain genetic properties (like having human leukocyte antigen (HLA) DQ2 or DQ8 haplotypes) is an important factor for the development of DH.²

Symptoms

DH patients are at risk of having the same symptoms as those with coeliac disease; however, 20% of individuals may have normal intestinal biopsy.⁴ But even with normal intestinal biopsy and normal blood tests (when performed for coeliac), patients still respond to gluten-free diets.⁴

Symptoms of DH include:⁸

• Lesions on the scalp, shoulders, elbows, knees and buttocks
• Itchy papules and vesicles on the skin
• Petechiae
• Flat red patches, thickened plaques, and wheals that can resemble other skin conditions like popular urticaria or scabies

DH can result in more complications, especially if it is associated with coeliac disease, like:⁸

• Dry skin, nails and hair abnormalities
• Thin enamel
• Heart disease
• Fatty liver
• Non-Hodgkin lymphoma
• Recurrent miscarriages
• Neurological issues like epilepsy
• Aphthous ulcer
• Angular cheilitis

Diagnosis

To test for DH, a blood test and skin biopsy are done to confirm this.⁴ For biopsy, once a skin sample is taken, it is tested through fluorescent dye for the presence of IgA, which gives a granular pattern.⁴ Skin biopsies are almost always positive for granular IgA pattern.⁴

Blood tests in DH will be done for antibodies that are also found in coeliac disease (e.g., TG2 and TG3).⁴ If the antibodies are positive and the skin biopsy gives the typical pattern and findings, then there is no need to do an intestinal biopsy for coeliac disease.⁴

Treatment 

Treatment for DH will include a strict gluten-free diet, which usually clears the skin lesions.⁴ Additionally, patients can be prescribed medication to relieve itching, such as dapsone.⁴ Dapsone has a strong effect on the rash and takes effect within 48-72 hours, but some patients may be intolerant to this medication.⁴ In such cases, alternative medicines are given like sulfapyridine or sulfasalazine, although they are less effective.⁴ Follow-up and long-term management will be required to check on the well-being of the individual.

Connection between coeliac disease and dermatitis herpetiformis

DH is considered a cutaneous manifestation of coeliac disease, and they both have HLA DQ2 and DQ8 haplotypes, with 90% of cases being HLA DQ2 and the rest being HLA DQ8.³ Around 10-15% of people that have coeliac disease will have dermatitis herpetiformis.⁴

Both conditions can affect our quality of life; for example, having these conditions will lead to dietary restrictions to avoid the symptoms. However, it is not always easy to find gluten-free stuff, depending on the area you are in. Additionally, they can affect day-to-day activities and even affect someone’s self-esteem.

Summary

Coeliac disease is an autoimmune disorder that is triggered by the ingestion of gluten. It can lead to multiple gastrointestinal symptoms like constipation, indigestion, and stomach pains. One of the manifestations of coeliac disease can present itself on the skin in the form of itchy lesions and blisters, known as dermatitis herpetiformis (DH). It is important to diagnose these cases early to avoid complications from occurring or even the emergence of other autoimmune disorders. Both coeliac and DH can be tested for through blood tests and biopsies, and both are usually treated through a strict gluten-free diet. It is important for us to take care of our health and make sure we have the appropriate diet for our bodies, as this can greatly affect our quality of life.