Case 1: Why haven't corticosteroids relieved these itchy spots?

March 1, 2009

A 44-year-old man seeks evaluation of itchy spots of 2 years’ duration on both forearms near the elbow. The condition failed to respond to topical corticosteroids prescribed by other physicians. Skin biopsy results were inconclusive; they showed only mild inflammation.

Case 1:

A 44-year-old man seeks evaluation of itchy spots of 2 years’ duration on both forearms near the elbow. The condition failed to respond to topical corticosteroids prescribed by other physicians. Skin biopsy results were inconclusive; they showed only mild inflammation.

What do you suspect?

A. Contact dermatitis.B. Psoriasis. C. Dermatitis herpetiformis.D. Folliculitis.E. Factitial dermatitis.

(Answer on next page.)


An immunofluorescence biopsy confirmed the diagnosis of dermatitis herpetiformis, C. This autoimmune disease presents as minute vesicles that are rarely seen because of excoriations; the areas around the knees and elbows and the sacral area are typically affected. This condition is usually lifelong and is antigenically stimulated by gluten. In addition to avoidance of gluten, the mainstay of treatment is dapsone.

 Contact dermatitis would usually not produce these discrete lesions; however, patch testing would be reasonable. Psoriasis affects the elbows but tends to be more hyperkeratotic than the eruption seen here. Folliculitis is usually tender; although Pityrosporum folliculitis is pruritic, it does not occur on the elbows. This patient was considered to have factitial dermatitis until the immunofluorescence biopsy established the correct diagnosis.