Autoimmune Disorders In Dermatitis Herpetiformis

What Are Autoimmune Disorders?

[dropcap]A[/dropcap]utoimmune disorders refer to those conditions that involve an abnormal attack on the body’s own tissues perpetuated by the production of autoantibodies directed against self.

Q: What happens when autoantibodies attack the body’s own tissues?

A: This abnormal immune activity by autoantibodies causes inflammation and damage to targeted body tissues.

Dermatitis herpetiformis is a skin manifestation of celiac disease characterized by extremely itchy blisters that commonly erupt on forearms and knees but may appear on the face, scalp or buttocks.

Autoimmune diseases as a group affect approximately 8.5% of people worldwide.

What Are Autoimmune Disorders In Dermatitis Herpetiformis?

• Autoimmune disorders in dermatitis herpetiformis are associated disorders.
• They are marked by increased risk of developing with increased delay in diagnosing gluten as the cause of dermatitis herpetiformis and with subsequent elimination of gluten from the diet. 
• The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.¹
• In the study by Reunula and Collins following 305 patients with dermatitis herpetiformis, the following associations were found: autoimmune thyroid disease 4.3%, insulin dependent diabetes mellitus 1.0%, lupus erythematosus 1.3%, Sjogrens syndrome 1.0%, sarcoidosis 1.3%, and vitiligo or alopecia areata 1.6%. Most of these diseases began before dermatitis herpetiformis had been diagnosed.²

How Prevalent Are Autoimmune Disorders In Dermatitis Herpetiformis?

Endocrine and connective tissue disorder associations occuring at the same time were found in 9.5% of patients with dermatitis herpetiformis over a mean of 10 years.²

What Are The Symptoms Of Autoimmune Disorders In Dermatitis Herpetiformis?

• Symptoms of autoimmune disorders are those of the individual disorders in addition to dermatitis herpetiformis.

Dematitis herpetiformis is marked by these symptoms:

• An extremely itchy and burning rash that appears as fluid filled blisters and red raised bumps on the elbows extending down lower arms on the side opposite the thumb, on the knees extending down the lower leg, trunk, and scalp.
• Rash can appear on other surfaces including the face and hands.

How Do Autoimmune Disorders In Dermatitis Herpetiformis Develop?

• Autoimmune disorders in dermatitis herpetiformis result from gluten exposure and a related autoimmune mechanism.

Do Autoimmune Disorders In Dermatitis Herpetiformis Respond To Gluten-Free Diet?

Patients already on a strict gluten free diet are not at special risk of contracting endocrine and connective tissue disorders.³

6 Steps To Improve Autoimmune Disorders In Dermatitis Herpetiformis:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both immune and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁴
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁵
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁵
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁵.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁵
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁵
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁵[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications used to supress dermatitis herpetiformis cause nutritional deficiencies that promote complications in celiac disease.   Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

• Dapsone depletes Vitamin K.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin K as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Autoimmune Disorders In Dermatitis Herpetiformis?

RESEARCH STUDY SUMMARIES

“Diseases associated with dermatitis herpetiformis.” This study investigating the occurrence of associated diseases in a cohort of 305 patients with dermatitis herpetiformis demonstrated that patients with dermatitis herpetiformis are similiar to patients with celiac disease in that many have associated endocrine or connective tissue disorders. The following associations were found: autoimmune thyroid disease 4.3%, IDDM 1.0%, lupus erythematosus 1.3%, Sjogrens syndrome 1.0%, sarcoidosis 1.3%, and vitiligo or alopecia areata 1.6%.  Most of these diseases began before dermatitis herpetiformis had been diagnosed.²

CASE REPORT SUMMARIES

“Transverse myelitis associated with an itchy rash and hyperckemia: neuromyelitis optica associated with dermatitis herpetiformis.” This case report describes a 53-year-old woman who initially presented with nausea and vomiting and was noted to have an asymptomatic elevated creatinine kinase level, which improved with conservative management. She had a history of iron-deficiency anemia due to long-standing celiac disease that was managed with a gluten-free diet.

She then presented with recurrent transverse myelitis and a vesicobullous rash over her arms and feet that was pruritic and excoriating. Skin biopsy results confirmed a clinical diagnosis of dermatitis herpetiformis and antibody test findings against aquaporin-4 were positive, leading to a diagnosis of neuromyelitis optica spectrum disorder. Neuromyelitis optica is associated with severe neurodisability if not recognized and treated promptly. The patient was treated with methylprednisolone sodium succinate, plasma exchange, and azathioprine and has remained in remission.⁶

“Dermatitis herpetiformis co-localised with vitiligo in a patient with autoimmune polyglandular syndrome.” This case report describes the unusual presentation of dermatitis herpetiformis co-localised with segmental vitiligo in a 37-year-old woman with a background history of autoimmune polyglandular syndrome type 2.

The patient presented with a 3-day history of a severe, itchy, bullous eruption on the trunk and limbs associated with malaise. Her past medical history included Addison’s disease, autoimmune hypothyroidism, type 1 diabetes mellitus, coeliac disease and vitiligo. Coeliac disease was diagnosed following distal duodenal biopsy which demonstrated subtotal villous atrophy. The patient reported strict adherence to a gluten-free diet. Vitiligo on the limbs, trunk, and neck was treated with moderate potency topical corticosteroids fourteen years prior to this acute presentation.

On examination, multiple, well-demarcated, segmental areas of depigmentation were present on the forearms, neck, groin, and upper thighs. There were vesicles and bullae of up to 20 mm in diameter with adjacent crusted, erythematous papules exclusively within the depigmented areas but not within the pigmented patches. She was managed with a gluten-free diet and hydroxyzine 25 mg when required. We propose genetic mosaicism as a possible mechanism. There has only been one previous case report in which dermatitis hepetiformis co-localised in close proximity but not exclusively within vilitigo in a patient with autoimmune thyroiditis.⁷

Sources:

1. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380. [↩]
2. Reunala T, Collin P. Diseases associated with dermatitis herpetiformis. British Journal of Dermatology. Mar 1997;136(3):315-8. [↩] [↩] [↩]
3. Reunala T, Collin P. Diseases associated with dermatitis herpetiformis. British Journal of Dermatology. Mar 1997;136(3):315-8. [↩]
4. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
5. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
6. Iyer A, Rathnasabapathi D, Elsone L, Mutch K, Terlizzo M, Footitt D, Jacob A. Transverse myelitis associated with an itchy rash and hyperckemia: neuromyelitis optica associated with dermatitis herpetiformis. JAMA Neurol. 2014 May;71(5):630-3. doi: 10.1001/jamaneurol.2013.6277. [↩]
7. Macbeth AE, Lee KY, Levell NJ, Igali L, Millington GW. Photoletter to the editor: Dermatitis herpetiformis co-localised with vitiligo in a patient with autoimmune polyglandular syndrome. J Dermatol Case Rep. 2013 Sep 30;7(3):101-2. doi: 10.3315/jdcr.2013.1153. [↩]