Photo Quiz

Persistent Pruritic Papulovesicles AMIT MISTRY, MD, and NISHA MISTRY, MD, FRCPC, DABD

The editors of AFP wel- A 32-year-old man presented with a chronic come submissions for rash on the extensor surface of his elbows Photo Quiz. Guidelines for preparing and submitting and on his buttocks. Small pruritic skin a Photo Quiz manuscript bumps had been appearing on and off for can be found in the several years. He also had episodes of alter- Authors’ Guide at http:// nating diarrhea and constipation for the www.aafp.org/afp/ photoquizinfo. To be con- previous six months. He had no recent travel sidered for publication, or exposures to illness. submissions must meet Figure 1. Physical examination revealed multiple these guidelines. E-mail erythematous, excoriated papulovesicles submissions to afpphoto@ aafp.org. Contributing edi- (Figures 1 and 2). He was afebrile and in no tor for Photo Quiz is John distress. E. Delzell, Jr., MD, MSPH. A collection of Photo Quiz- Question zes published in AFP is Based on the patient’s history and physical available at http://www. examination findings, which one of the fol- aafp.org/afp/photoquiz. lowing is the most likely diagnosis? ❑ A. Bullous pemphigoid. ❑ B. Dermatitis herpetiformis. ❑ C. Erythema multiforme. ❑ D. Folliculitis. See the following page for discussion.

Figure 2.

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Summary Table

Condition Cause Characteristics

Bullous Autoimmune disease Recurrent tense bullae; subepidermal blisters with pemphigoid eosinophilic infiltration; usually occurs in older persons Dermatitis Autoimmune disease; cutaneous presentation of Pruritic clusters of papules and vesicles on the extensor herpetiformis gluten sensitive enteropathy (celiac disease) surfaces of the elbows and knees, the buttocks, and the back Erythema Type IV hypersensitivity reaction to infections or Target-like lesions, usually on the palms and soles; multiforme medications papules, plaques, and bullae Folliculitis Infection and inflammation of hair follicles; often Erythematous papules on any hair-bearing site, sparing bacterial (Staphylococcus, Pseudomonas) the palms and soles

Discussion penicillin, phenytoin [Dilantin], nonsteroi- The answer is B: dermatitis herpetiformis. dal anti-inflammatory drugs, sulfa drugs) This autoimmune disease is the cutaneous or infection (e.g., herpes simplex virus, presentation of gluten sensitive enteropathy mycoplasma). It presents with target-like (celiac disease).1 Dermatitis herpetiformis is lesions, usually on the palms and soles, but characterized by pruritic clusters of pap- it can also occur on the trunk. The lesions ules and vesicles on the extensor surfaces can be multiforme, with papules, plaques, of the elbows and knees, the buttocks, and and bullae.4 the back. The primary lesions are often not Folliculitis is a superficial infection and seen because they are quickly excoriated. inflammation of hair follicles manifesting The pruritus can cause significant discomfort as erythematous papules. The eruption can and insomnia. Histologic examination reveals be pruritic and occurs on any hair-bearing neutrophilic microabscesses in the dermal site, sparing the palms and soles. Staphylo- papillae. A perilesional skin biopsy with direct coccus and Pseudomonas infections are com- immunofluorescence shows granular deposits mon causes.5 of immunoglobulin A (IgA) in the upper Address correspondence to Amit Mistry, MD, at papillary dermis. Avoidance of dietary gluten [email protected]. Reprints are not available is the primary treatment, but it is a chronic from the authors. disease that requires continuous monitoring Author disclosure: No relevant financial affiliations. and may take several months to improve.2 Dapsone can be used to treat the pruritus. REFERENCES Bullous pemphigoid is an autoimmune 1. Zone JJ. Skin manifestations of celiac disease. Gastro- blistering disease that most commonly enterology. 2005;128(4 suppl 1):S87-S91. affects older persons. It presents with tense 2. Hull CM, Liddle M, Hansen N, et al. Elevation of IgA bullae that can recur over months to years. anti-epidermal transglutaminase antibodies in dermati- Histologic examination shows subepidermal tis herpetiformis. Br J Dermatol. 2008;159(1):120-124. blisters with eosinophilic infiltration. The 3. Korman NJ. Bullous pemphigoid. Cutan Med Surg. 1996;664-673. proinflammatory response is mediated by 4. Sokumbi O, Wetter DA. Clinical features, diagnosis, IgG and C3, which are linearly deposited and treatment of erythema multiforme: a review along the dermoepidermal junction.3 for the practicing dermatologist. Int J Dermatol. Erythema multiforme is a self-limited, 2012;51(8):889-902. 5. Eley CD, Gan VN. Picture of the month. Folliculitis, type IV hypersensitivity reaction that is furunculosis, and carbuncles. Arch Pediatr Adolesc usually secondary to medication use (e.g., Med. 1997;151(6):625-626. ■

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