BACKGROUND: Dermatitis herpetiformis (DH) is a rare autoimmune blistering disease characterized by pruritic papulovesicular eruptions. It can be differentiated from other vesiculobullous skin diseases by skin biopsy with direct immunofluorescence. DH is most often associated with gluten enteropathy (celiac disease) also an uncommon disease.

CASE PRESENTATION: We report a case of a 20-year-old male with a five-week history of multiple vesicles and bullae associated with fever and body malaise. Lesions were symmetrically found on the entire face, axillae, trunk, buttocks and lower extremities. Hematology revealed leukocytosis with neutrophilic predominance. Skin punch biopsy revealed subepidermal blister with neutrophilic predominance. A direct immunofluorescence (DIP) of the perilesional skin showed granular IgA staining at the tips of the dermal papillae, consistent of DH.

TREATMENT AND OUTCOME: The patient was started with cloxacillin and mupirocin ointment for the infected skin lesions. Dapsone 100 mg daily was started with significant improvement of lesions after seven days. Endoscopy was suggested to investigate for gluten enteropathy, however patient did not consent. The patient was advised on gluten-free diet (GED). Complete resolution of lesions with postinflamamtory hypo- and hyperpigmented scarring were noted after nine weeks of dapsone therapy.

CONCLUSION: Bullous skin lesions present as a great challenge to non-dermatologists, hence a thorough investigation was clearly of utmost importance in arriving at a diagnosis of DH in this case. Internists must be aware that skin lesions could provide clues of other internal diseases, such as in DH and gluten enteropathy. Treatment of DH can be as simple as diet modification and avoidance of gluten¬containing food.