to the editor: In the article, “Autoimmune Bullous Dermatoses: A Review,”¹ one of the conditions the authors discuss is dermatitis herpetiformis. They suggest that gluten-sensitive enteropathy (celiac disease) is an associated manifestation of dermatitis herpetiformis and that a gluten-free diet is one way to treat dermatitis herpetiformis. I think dermatitis herpetiformis should rather be thought of as a variant or complication of untreated celiac disease.² Supporting this is the fact that dermatitis herpetiformis and celiac disease share the same human leukocyte antigen haplotype and show similar results on serum and intestinal antibody testing. Typical pathologic changes of celiac disease are found on small intestinal biopsy in almost 100 percent of patients with dermatitis herpetiformis.²

A gluten-free diet should be recommended for life in patients with dermatitis herpetiformis. Longer duration of exposure to gluten has been associated with a higher incidence of autoimmune disorders such as type 1 diabetes, connective tissue diseases, autoimmune thyroid disease, and autoimmune hepatitis.³ Nonautoimmune complications of untreated celiac disease include osteoporosis, iron deficiency anemia and, most ominously, small intestinal lymphoma.

Silent and atypical celiac disease (dermatitis herpetiformis being an example of the latter) are now known to be common.⁴ All patients with dermatitis herpetiformis should be considered to have celiac disease, and a gluten-free diet should be recommended for life.

In reply: I would like to thank Dr. Lovett for reiterating the importance of a gluten-free diet in the treatment of dermatitis herpetiformis. In Table 2 of our article,¹ we list gluten-free diet as the first treatment of dermatitis herpetiformis and indicate that sulfones (Dapsone) are beneficial for the skin lesions only. As a dermatologist, I recommend a gluten-free diet and a gastroenterologic consultation for all of my patients who have dermatitis herpetiformis. I reserve sulfones for patients who are symptomatic and want immediate relief from their pruritus.