subcorneal
intraepidermal
subepidermal
pemphigus
nikolski's sign
pemphigus foliaceous
pemphigus vulgaris
pseudonikolski's sign
revision notes for dermatology based on lecture notes and high yield topic
based on previous year question
Erythema multiforme, Steven-Johnson syndrome and Toxic Epidermal NecrolysisBinaya Subedi
Erythema Multiforme is a common Vesiculobullous deramtological condition with mucosal manifestations trigged by Herpes virus infection and certain sulpha containing drugs.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
• Actinomyces species are classified as anaerobic, gram positive and filamentous bacteria.
• It is a chronic granulomatous suppurative and fibrosing disease caused by anaerobic or microaerophilic gram-positive nonacid fast, branched filamentous bacteria.
• Most of the species isolated from actinomycotic lesions have been identified as A. israelii, A. viscosus, A. odontolyticus, A.naeslundii or A. meyeri.
• These microorganisms have been identified in dental plaque, dental calculus, necrotic pulp, and tonsils.
• The usual pattern of this disease is one characterized chiefly by the formation of abscesses that tend to drain by the formation of sinus tracts.
• pus from the abscesses is examined on a clean glass slide, it shows the typical ‘sulfur granules’ or colonies of organisms, which appear in the suppurative material as tiny, yellow grains.
• Another infection that produces this type of sulfur granules is botryomycosis.
subcorneal
intraepidermal
subepidermal
pemphigus
nikolski's sign
pemphigus foliaceous
pemphigus vulgaris
pseudonikolski's sign
revision notes for dermatology based on lecture notes and high yield topic
based on previous year question
Erythema multiforme, Steven-Johnson syndrome and Toxic Epidermal NecrolysisBinaya Subedi
Erythema Multiforme is a common Vesiculobullous deramtological condition with mucosal manifestations trigged by Herpes virus infection and certain sulpha containing drugs.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
• Actinomyces species are classified as anaerobic, gram positive and filamentous bacteria.
• It is a chronic granulomatous suppurative and fibrosing disease caused by anaerobic or microaerophilic gram-positive nonacid fast, branched filamentous bacteria.
• Most of the species isolated from actinomycotic lesions have been identified as A. israelii, A. viscosus, A. odontolyticus, A.naeslundii or A. meyeri.
• These microorganisms have been identified in dental plaque, dental calculus, necrotic pulp, and tonsils.
• The usual pattern of this disease is one characterized chiefly by the formation of abscesses that tend to drain by the formation of sinus tracts.
• pus from the abscesses is examined on a clean glass slide, it shows the typical ‘sulfur granules’ or colonies of organisms, which appear in the suppurative material as tiny, yellow grains.
• Another infection that produces this type of sulfur granules is botryomycosis.
Vasculitis syndrome an approach -and-basic principles of treatmentSachin Verma
Vasculitides are a hetrogenous group of conditions characterized by inflammation and necrosis of blood vessels.
A broad group of syndromes may result from this process,since any type,size, and location of vessel may be involved.
A simplified guide to the most common diseases with fever & rash especially in pediatrics. The data have been trimmed as much as possible and focused on spot visual diagnosis of the disease.
Eczema, also known as atopic dermatitis, is a serious skin problem. Once it appears, eczema can last weeks or months. Eczema usually occurs in people with a personal or family history of atopy (allergic asthma, rhinitis, conjunctivitis, or food allergies).
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
A rare case report...
Dr. Suresh Kumar
International Journal of Recent Trends in Science and Technology Volume 10, Issue 2, 2014.
http://statperson.com/Journal/ScienceAndTechnology/Volume10Issue2.php
Please find your Research Article IJRTSAT_10_2_24.
DEVELOPMENTAL DISTURBANCES OF ORAL LYMPHOID TISSUE / dental crown & bridge co...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
PHP Frameworks: I want to break free (IPC Berlin 2024)Ralf Eggert
In this presentation, we examine the challenges and limitations of relying too heavily on PHP frameworks in web development. We discuss the history of PHP and its frameworks to understand how this dependence has evolved. The focus will be on providing concrete tips and strategies to reduce reliance on these frameworks, based on real-world examples and practical considerations. The goal is to equip developers with the skills and knowledge to create more flexible and future-proof web applications. We'll explore the importance of maintaining autonomy in a rapidly changing tech landscape and how to make informed decisions in PHP development.
This talk is aimed at encouraging a more independent approach to using PHP frameworks, moving towards a more flexible and future-proof approach to PHP development.
DevOps and Testing slides at DASA ConnectKari Kakkonen
My and Rik Marselis slides at 30.5.2024 DASA Connect conference. We discuss about what is testing, then what is agile testing and finally what is Testing in DevOps. Finally we had lovely workshop with the participants trying to find out different ways to think about quality and testing in different parts of the DevOps infinity loop.
Let's dive deeper into the world of ODC! Ricardo Alves (OutSystems) will join us to tell all about the new Data Fabric. After that, Sezen de Bruijn (OutSystems) will get into the details on how to best design a sturdy architecture within ODC.
Kubernetes & AI - Beauty and the Beast !?! @KCD Istanbul 2024Tobias Schneck
As AI technology is pushing into IT I was wondering myself, as an “infrastructure container kubernetes guy”, how get this fancy AI technology get managed from an infrastructure operational view? Is it possible to apply our lovely cloud native principals as well? What benefit’s both technologies could bring to each other?
Let me take this questions and provide you a short journey through existing deployment models and use cases for AI software. On practical examples, we discuss what cloud/on-premise strategy we may need for applying it to our own infrastructure to get it to work from an enterprise perspective. I want to give an overview about infrastructure requirements and technologies, what could be beneficial or limiting your AI use cases in an enterprise environment. An interactive Demo will give you some insides, what approaches I got already working for real.
Essentials of Automations: Optimizing FME Workflows with ParametersSafe Software
Are you looking to streamline your workflows and boost your projects’ efficiency? Do you find yourself searching for ways to add flexibility and control over your FME workflows? If so, you’re in the right place.
Join us for an insightful dive into the world of FME parameters, a critical element in optimizing workflow efficiency. This webinar marks the beginning of our three-part “Essentials of Automation” series. This first webinar is designed to equip you with the knowledge and skills to utilize parameters effectively: enhancing the flexibility, maintainability, and user control of your FME projects.
Here’s what you’ll gain:
- Essentials of FME Parameters: Understand the pivotal role of parameters, including Reader/Writer, Transformer, User, and FME Flow categories. Discover how they are the key to unlocking automation and optimization within your workflows.
- Practical Applications in FME Form: Delve into key user parameter types including choice, connections, and file URLs. Allow users to control how a workflow runs, making your workflows more reusable. Learn to import values and deliver the best user experience for your workflows while enhancing accuracy.
- Optimization Strategies in FME Flow: Explore the creation and strategic deployment of parameters in FME Flow, including the use of deployment and geometry parameters, to maximize workflow efficiency.
- Pro Tips for Success: Gain insights on parameterizing connections and leveraging new features like Conditional Visibility for clarity and simplicity.
We’ll wrap up with a glimpse into future webinars, followed by a Q&A session to address your specific questions surrounding this topic.
Don’t miss this opportunity to elevate your FME expertise and drive your projects to new heights of efficiency.
Connector Corner: Automate dynamic content and events by pushing a buttonDianaGray10
Here is something new! In our next Connector Corner webinar, we will demonstrate how you can use a single workflow to:
Create a campaign using Mailchimp with merge tags/fields
Send an interactive Slack channel message (using buttons)
Have the message received by managers and peers along with a test email for review
But there’s more:
In a second workflow supporting the same use case, you’ll see:
Your campaign sent to target colleagues for approval
If the “Approve” button is clicked, a Jira/Zendesk ticket is created for the marketing design team
But—if the “Reject” button is pushed, colleagues will be alerted via Slack message
Join us to learn more about this new, human-in-the-loop capability, brought to you by Integration Service connectors.
And...
Speakers:
Akshay Agnihotri, Product Manager
Charlie Greenberg, Host
Dev Dives: Train smarter, not harder – active learning and UiPath LLMs for do...UiPathCommunity
💥 Speed, accuracy, and scaling – discover the superpowers of GenAI in action with UiPath Document Understanding and Communications Mining™:
See how to accelerate model training and optimize model performance with active learning
Learn about the latest enhancements to out-of-the-box document processing – with little to no training required
Get an exclusive demo of the new family of UiPath LLMs – GenAI models specialized for processing different types of documents and messages
This is a hands-on session specifically designed for automation developers and AI enthusiasts seeking to enhance their knowledge in leveraging the latest intelligent document processing capabilities offered by UiPath.
Speakers:
👨🏫 Andras Palfi, Senior Product Manager, UiPath
👩🏫 Lenka Dulovicova, Product Program Manager, UiPath
Epistemic Interaction - tuning interfaces to provide information for AI supportAlan Dix
Paper presented at SYNERGY workshop at AVI 2024, Genoa, Italy. 3rd June 2024
https://alandix.com/academic/papers/synergy2024-epistemic/
As machine learning integrates deeper into human-computer interactions, the concept of epistemic interaction emerges, aiming to refine these interactions to enhance system adaptability. This approach encourages minor, intentional adjustments in user behaviour to enrich the data available for system learning. This paper introduces epistemic interaction within the context of human-system communication, illustrating how deliberate interaction design can improve system understanding and adaptation. Through concrete examples, we demonstrate the potential of epistemic interaction to significantly advance human-computer interaction by leveraging intuitive human communication strategies to inform system design and functionality, offering a novel pathway for enriching user-system engagements.
State of ICS and IoT Cyber Threat Landscape Report 2024 previewPrayukth K V
The IoT and OT threat landscape report has been prepared by the Threat Research Team at Sectrio using data from Sectrio, cyber threat intelligence farming facilities spread across over 85 cities around the world. In addition, Sectrio also runs AI-based advanced threat and payload engagement facilities that serve as sinks to attract and engage sophisticated threat actors, and newer malware including new variants and latent threats that are at an earlier stage of development.
The latest edition of the OT/ICS and IoT security Threat Landscape Report 2024 also covers:
State of global ICS asset and network exposure
Sectoral targets and attacks as well as the cost of ransom
Global APT activity, AI usage, actor and tactic profiles, and implications
Rise in volumes of AI-powered cyberattacks
Major cyber events in 2024
Malware and malicious payload trends
Cyberattack types and targets
Vulnerability exploit attempts on CVEs
Attacks on counties – USA
Expansion of bot farms – how, where, and why
In-depth analysis of the cyber threat landscape across North America, South America, Europe, APAC, and the Middle East
Why are attacks on smart factories rising?
Cyber risk predictions
Axis of attacks – Europe
Systemic attacks in the Middle East
Download the full report from here:
https://sectrio.com/resources/ot-threat-landscape-reports/sectrio-releases-ot-ics-and-iot-security-threat-landscape-report-2024/
Empowering NextGen Mobility via Large Action Model Infrastructure (LAMI): pav...
Vesiculobullous diseases
1. CLASSIFICATION OF VESICULOBULLOUSCLASSIFICATION OF VESICULOBULLOUS
DISEASESDISEASES
VESICLE & BULLAVESICLE & BULLA
A clear fluid lesion just below theA clear fluid lesion just below the
epithelium which ruptures to form an ulcer,epithelium which ruptures to form an ulcer,
if this is smaller than 5mm then it is aif this is smaller than 5mm then it is a
vesicle ,if larger than 5mm than it is a bullavesicle ,if larger than 5mm than it is a bulla
2. CLASSIFICATION OF VESICULOBULLOUSCLASSIFICATION OF VESICULOBULLOUS
DISEASESDISEASES
CLASSIFICATIONCLASSIFICATION
INTRA EPITHELIAL VESICLESINTRA EPITHELIAL VESICLES: The lesion is formed: The lesion is formed
within the epitheliumwithin the epithelium
Acantholytic vesicles :Acantholytic vesicles : This is because of the breakThis is because of the break
down of specialized attachments called thedown of specialized attachments called the
desmosomesdesmosomes
Nonacantholytic vesiclesNonacantholytic vesicles: It is usually in the viral: It is usually in the viral
infections because of the death or the rupture of theinfections because of the death or the rupture of the
group of cells.group of cells.
SUB EPITHELIAL VESICLESSUB EPITHELIAL VESICLES: Lesions formed between the: Lesions formed between the
epithelium and the lamina propria eg:epithelium and the lamina propria eg:
Erthyma multifomeErthyma multifome
PhempegoidPhempegoid
Dermatitis herpetiformisDermatitis herpetiformis
Epidermolysis bullosaEpidermolysis bullosa
3. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
Autoimmune disease.Autoimmune disease.
Common in Ashkenazi and Mediterranean jews .Common in Ashkenazi and Mediterranean jews .
Middle aged females.Middle aged females.
Other variants are:Other variants are:
Pemphius vegetansPemphius vegetans
Paraneoplastic pemphgusParaneoplastic pemphgus
4. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
CLINICAL FEATURES:CLINICAL FEATURES:
Painful ulcers or bulla are formed which are fluidPainful ulcers or bulla are formed which are fluid
filled.filled.
They can be formed any where in the oral cavity .They can be formed any where in the oral cavity .
The bulla is rapidly ruptured leaving a collapsed roofThe bulla is rapidly ruptured leaving a collapsed roof
of grayish membrane with a red ulcerated base.Theof grayish membrane with a red ulcerated base.The
ulcer may look like an apthous ulcer or may be largeulcer may look like an apthous ulcer or may be large
map shaped.map shaped.
Nikolsky sign is positive.Nikolsky sign is positive.
5. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
Sometimes the ulcers are joined together to make aSometimes the ulcers are joined together to make a
confluence. this condition is very painful.confluence. this condition is very painful.
It has a variable course might involve skin,It has a variable course might involve skin,
oesophagus, cervix.oesophagus, cervix.
Protein/fluid,electrolyte and weight loss /secondaryProtein/fluid,electrolyte and weight loss /secondary
infections.infections.
Fatal if untreated.Fatal if untreated.
7. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
PATHOGENESIS:PATHOGENESIS:
It is an autoimmune diseaseIt is an autoimmune disease
There are circulating antibodies of type IgG.There are circulating antibodies of type IgG.
These antibodies are reactive against theThese antibodies are reactive against the
desmosomes or the tonofilament complex.desmosomes or the tonofilament complex.
There destruction or disruption of theseThere destruction or disruption of these
tonofilament complex ,resulting in the loss oftonofilament complex ,resulting in the loss of
attachment from cell to cellattachment from cell to cell
path.cont…dpath.cont…d
8.
9. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
HISTOPATHOLOGY:HISTOPATHOLOGY:
Intra epithelial vesicles or bulla and cleft like spacesIntra epithelial vesicles or bulla and cleft like spaces
are produced by acantolysis .are produced by acantolysis .
These changes are in the stratum spinosum or theThese changes are in the stratum spinosum or the
prickle cell layerprickle cell layer
Inflammatory cells are very scanty howeverInflammatory cells are very scanty however
eosinophils may be seen.eosinophils may be seen.
Acantholytic statum spinosum cells occur singly orAcantholytic statum spinosum cells occur singly or
are in the forms of clumps lying freely within theare in the forms of clumps lying freely within the
blister fluid. These cell loose there polyhedralblister fluid. These cell loose there polyhedral
morphology rather they are small rounded andmorphology rather they are small rounded and
contain hyper chromatic nuclei called the TZANKcontain hyper chromatic nuclei called the TZANK
CELLS.CELLS.
12. DIAGNOSISDIAGNOSIS
Skin biopsySkin biopsy
Electron microscopy has shown thatElectron microscopy has shown that
widening of the intercellular space iswidening of the intercellular space is
followed by splitting of the desmosomefollowed by splitting of the desmosome
junctions.junctions.
Direct & indirect immunofluorescenceDirect & indirect immunofluorescence
ELISAELISA
16. PEMPHIGUS VULGARISPEMPHIGUS VULGARIS
TREATMENT:TREATMENT:
High mortality rates previouslyHigh mortality rates previously
Introduction of systemic corticosteroidsIntroduction of systemic corticosteroids
like prednisolone in stable cases.like prednisolone in stable cases.
Prednisolone plus azathioprinePrednisolone plus azathioprine
methotrexate and cyclophosphamide inmethotrexate and cyclophosphamide in
progressed or advanced cases.progressed or advanced cases.
18. DefinitionDefinition: Blistering in this group of: Blistering in this group of
autoimmune diseases is high in theautoimmune diseases is high in the
epidermis, either in the granular layer orepidermis, either in the granular layer or
just beneath the stratum corneum.just beneath the stratum corneum.
Antibody binding may have a direct effectAntibody binding may have a direct effect
on the function of the desmosomalon the function of the desmosomal
cadherins in the upper epidermis, causingcadherins in the upper epidermis, causing
detachment of keratinocytes.detachment of keratinocytes.
Desmoglein-l is present but only weaklyDesmoglein-l is present but only weakly
expressed in mucosae accounting for theexpressed in mucosae accounting for the
lack of mucosal involvement inlack of mucosal involvement in
pemphigus foliaceus.pemphigus foliaceus.
19. Clinical featureClinical feature
The onset is usually insidious with scattered, scalyThe onset is usually insidious with scattered, scaly
lesions involving the 'seborrhoeic' areas: scalp,lesions involving the 'seborrhoeic' areas: scalp,
face, chest and upper back. Blistering may not beface, chest and upper back. Blistering may not be
obvious because the cleavage is superficial and theobvious because the cleavage is superficial and the
small flaccid blisters rupture easily.small flaccid blisters rupture easily.
Oral lesions are uncommon.Oral lesions are uncommon.
Pemphigus foliaceus is generally regarded as aPemphigus foliaceus is generally regarded as a
benign disease which responds well to treatmentbenign disease which responds well to treatment
and may remit.and may remit.
22. TREATMENTTREATMENT
Potent topical or intralesional steroids or, ifPotent topical or intralesional steroids or, if
control is inadequate, prednisolone 20-40control is inadequate, prednisolone 20-40
mg/ day.mg/ day.
Azathioprine or cyclophosphamide areAzathioprine or cyclophosphamide are
effective adjuncts to oral steroids in severeeffective adjuncts to oral steroids in severe
cases. Hydroxychloroquine 200/mg twicecases. Hydroxychloroquine 200/mg twice
per day has also been recommended asper day has also been recommended as
adjuvant therapy. Intravenous Ig has beenadjuvant therapy. Intravenous Ig has been
reported as effective in resistant cases.reported as effective in resistant cases.
23. BULLOUS PEMPHIGOIDBULLOUS PEMPHIGOID
Bullous pemphigoid is an affliction of elderlyBullous pemphigoid is an affliction of elderly
people,with onset usually after 60 years ofpeople,with onset usually after 60 years of
age.age.
The blister in bullous pemphigoid isThe blister in bullous pemphigoid is
subepidermal with an intact and often viablesubepidermal with an intact and often viable
epidermis forming the roof.epidermis forming the roof.
Bullous pemphigoid commonly starts withBullous pemphigoid commonly starts with
itching and a non-specific rash on the limbsitching and a non-specific rash on the limbs
that may be either urticaria-like orthat may be either urticaria-like or
occasionally eczematous and rarely mayoccasionally eczematous and rarely may
simulate vesicular eczema.simulate vesicular eczema.
24.
25. PEMPHGOIDPEMPHGOID
Blisters may arise on erythematous and onBlisters may arise on erythematous and on
normal skin and may be associated with dermalnormal skin and may be associated with dermal
edema. The blisters are tense and domeedema. The blisters are tense and dome
shaped, obtaining a diameter of manyshaped, obtaining a diameter of many
centimeteres.centimeteres.
The blisters are tough and may remain intact forThe blisters are tough and may remain intact for
several days, the contents often becoming jelly-several days, the contents often becoming jelly-
like with coagulated fibrin.like with coagulated fibrin.
Mucosal lesions occur less frequently and areMucosal lesions occur less frequently and are
less severe than in pemphigus vulgaris and areless severe than in pemphigus vulgaris and are
usually confined to the mouth.usually confined to the mouth.
28. PEMPHGOIDPEMPHGOID
Untreated bullous pemphigoid runs aUntreated bullous pemphigoid runs a
chronic, self limiting course over a numberchronic, self limiting course over a number
of months or years.of months or years.
The disease duration is usually 3-6 years,The disease duration is usually 3-6 years,
with most patients achieving completewith most patients achieving complete
remission off treatment.remission off treatment.
29. TREATMENTTREATMENT
Topical and systemic steroids are theTopical and systemic steroids are the
mainstay of treatment. For localized BP,mainstay of treatment. For localized BP,
very potent topical steroids are oftenvery potent topical steroids are often
sufficient.sufficient.
Corticosteroid therapy has lowered theCorticosteroid therapy has lowered the
morbidity from the disease considerablymorbidity from the disease considerably
and most patients achieve remission off alland most patients achieve remission off all
therapy, but significant mortality of bulloustherapy, but significant mortality of bullous
pemphigoid still remains at 15-40%, and ispemphigoid still remains at 15-40%, and is
nearly always treatment related or relatednearly always treatment related or related
to the general condition and age of theto the general condition and age of the
patients.patients.
30. DERMATITIS HERPETIFORMIS
Definition. Dermatitis herpetiformis (DH) is a
rare, intensely pruritic,chronic, recurrent,
papulovesicular disease.There is an underlying
gluten-sensitive enteropathy that may be
asymptomatic. The mechanism by which
ingestion of gluten induces granular IgA
deposition in the skin and blistering is still
obscure.
There is a family history of dermatitis
herpetiformis or coeliac disease in 10.5% of
patients and it has been reported to be both
concordant and discordant in monozygotic twins.
31. PATHOGENESIS
The IgA deposits are gluten dependent, and are slowly
cleared from the skin once gluten is removed from the
diet. The Ag within normal human skin to which IgA
antibodies from DH sera bind is still unknown.
One of the most exciting developments of recent years
has been the recognition that autoantibodies and T-cell
reactions to tissue transglutaminases, and in particular
transglutaminase 2, are relevant to the pathogenesis of
coeliac disease .These antibodies have been
demonstrated in dermatitis herpetiformis.In addition, it is
now clear that the previously recognized antireticulin and
endomysial antibodies, in coeliac disease and dermatitis
herpetiformis, are associated with these antibodies and
require transglutaminase 2 to bind to tissues.
32. PATHOLOGY
Diagnostic histological changes are best seen in
the vicinity of early blisters or in lesions that
have not yet blistered.Neutrophils and
eosinophils accumulate within the dermal
papillae and form microabscesses. The
surrounding collagen is degraded, resulting in
detachment of the epidermis and a
subepidermal vesicle. Multilocular vesicles may
coalesce to form blisters; Direct
immunofluorescence is always positive. There
are granular deposits of IgA in the dermal
papillae There may also be C3 and IgG.
34. CLINICAL FEATURES
Dermatitis herpetiformis presents mainly between the
ages of 20 and 55 years, but can present both in
childhood and old age. The onset may be acute or
gradual, and pruritus is usually the first and predominant
symptom. Early lesions on the skin are erythematous
papules, urticarial weals or groups of small vesicles often
excoriated so rapidly that it may be impossible to find
one intact. The vesicles are usually grouped together on
plaques of erythema, and rarely blisters 1-2 cm in
diameter occur.
The distribution of the lesions is characteristic. The
extensor aspects of the limbs, especially the knees, just
below the point of the elbows, buttocks and the natal
cleft, are affected in the majority of patients The axillary
folds, shoulders, trunk, face and scalp are all frequently
involved.
35. There may be a feeling of malaise with the acutely active
disease. In addition, constitutional symptoms due to the
glutensensitive enteropathy can be present. The patient
may experience bouts of abdominal pain, constipation
and diarrhoea, and be undernourished.
Associated diseases. There are often associated
autoimmune diseases, particularly thyroid disease,
pernicious anaemia and diabetes.There is an association
with thyroid disease in up to 30% of patients. Lymphoma
is a well-recognized complication of dermatitis
herpetiformis, as are other malignancies although a
recent study contradicts this . Moreover, the protective
role of a gluten-free diet for the lymphomas has been
established.
36.
37. Differential diagnosis
The diagnosis should be suspected when any
persistent, pruritic, symmetrical eruption resists
topical treatment. In view of the pruritus and
involvement of the axillary folds and buttocks,
many patients are thought to have scabies, but
the absence of burrows or of contact cases
should help with the diagnosis. The most difficult
diagnostic problem is the group of patients with
chronic exudative eczema, papular urticaria and
chronic prurigo, some of whom may be dapsone
responsive. The histology and the lack of IgA
deposition should help establish the correct
diagnosis.
38. TREATMENT
Dapsone is the most widely used treatment for dermatitis
herpetiformis. The dose needed for the average case is
100-200 mg/ day but a few may require 400 mg/ day.
Patients at risk of glucose-6-phosphate dehydrogenase
deficiency should be screened prior to treatment.
Methaemoglobinaemia is common, reaching a steady
state after about 2 weeks, and may cause cyanosis,
breathlessness and angina. Hepatitis, the dapsone
syndrome (lymphadenopathy and hepatitis) and
agranulocytosis are serious, usually early complications.
Motor neuropathy may occur.
Although systemic corticosteroids are in the main
ineffective and not indicated, topical steroids may be
helpful in lessening symptoms.
39. A gluten-free diet is the treatment of choice in
the long term. It has been shown not only to
improve the enteropathy, but also to allow
discontinuation of drug therapy. It is usually
many months and sometimes years before
patients are able to reduce their dapsone
requirements. Often dapsone can be
discontinued altogether after 2-3 years on a
strict gluten-free diet, but some patients take
much longer . Reintroduction of gluten in
selected patients produced a relapse in skin
lesions .The gluten-free diet after 5-10 years
protects patients from lymphoma, and this is an
additional reason to recommend a gluten-free
diet.