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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 43-45

Tetracyclines and niacinamide to the rescue in a case of dermatitis herpetiformis


1 Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
2 Paramount General Hospital, Mumbai, Maharashtra, India

Date of Submission13-Jul-2021
Date of Decision17-Nov-2021
Date of Acceptance11-Feb-2022
Date of Web Publication11-Jun-2022

Correspondence Address:
Siddhi Chikhalkar
Department of Dermatology, Ward 17/18, Seth G.S. Medical College and KEM Hospital, Mumbai 400012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_32_21

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How to cite this article:
Singh S, Chikhalkar S, Kharkar V, Oswal P. Tetracyclines and niacinamide to the rescue in a case of dermatitis herpetiformis. Indian J Drugs Dermatol 2022;8:43-5

How to cite this URL:
Singh S, Chikhalkar S, Kharkar V, Oswal P. Tetracyclines and niacinamide to the rescue in a case of dermatitis herpetiformis. Indian J Drugs Dermatol [serial online] 2022 [cited 2022 Sep 29];8:43-5. Available from: https://www.ijdd.in/text.asp?2022/8/1/43/347288



Sir

Dermatitis herpetiformis (DH) is a rare autoimmune blistering disorder characterized by grouped papulovesicular lesions on an erythematous or urticarial background that is liable to be misdiagnosed.[1] We report a patient with severe DH who was treated effectively with a combination of tetracycline and nicotinamide. A 61-year-old male presented with intensely itchy skin lesions on the back, buttocks, and limbs since 8 months. He has been diagnosed with atopic dermatitis and sebopsoriasis and treated with systemic and topical steroids and antihistamines with no relief. He had no gastrointestinal complaints. Examination revealed extensive papulovesicular, excoriated, and crusted erosions on the back, chest, face, scalp, forearm, and thigh [Figure 1] and [Figure 2]. Grouped tense vesicles were present over the right foot and knees [Figure 3] and [Figure 4]. Flexural areas, palms, soles, and mucosae were spared. A provisional diagnosis of vesicular bullous pemphigoid and DH was considered. Considering the clinical diagnosis of bullous pemphigoid, the patient was started on tetracycline 500 mg four times a day and niacinamide 250 mg four times a day. On investigation, hematological investigations, including hemogram, serum biochemistry, and urinalysis, were within normal limits. Histopathology of an intact vesicular lesion and papule revealed subepidermal bulla with neutrophilic abscesses at the tip of dermal papillae [Figure 5], and granular staining of the dermal papillae with immunoglobulin A (IgA) was noted on direct immunofluorescence (DIF), confirming the diagnosis of DH [Figure 6]. The same treatment was continued, and there was a dramatic reduction in the severity of itching and arrest of new lesions within 48 h, and complete remission within 2 weeks, which is maintained till date.
Figure 1: (a) Extensive papulovesicular lesions on the face. (b) Clearance of lesions following treatment

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Figure 2: (a) Excoriated papules and vesicles on the back. (b) The resolution of lesions with postinflammatory hyperpigmentation

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Figure 3: (a) Grouped tense vesicles over the knees. (b) Clinical picture showing resolution of lesions on knees

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Figure 4: (a) Grouped tense vesicles over the dorsal aspect of the right foot. (b) A clinical image showing the resolution of lesions with scaling

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Figure 5: (a) Histopatholgy showing subepidermal split. (b) Loculated vesicles in the epidermis

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Figure 6: DIF—Granular staining of the dermal papillae with IgA

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Even though the drug of choice is dapsone,[2] there are multiple alternative therapies when dapsone is contraindicated. They are cholestyramine, sodium cromoglycate, sulfasalazine,[2] heparin,[3] tetracycline and niacinamide, and cyclosporine. Tetracycline acts by suppressing complement-mediated inflammatory reactions; leukocyte chemotaxis at the basement membrane inhibits metalloproteinase activity.[4]Niacinamide is a free radical scavenger, acts by inhibiting eosinophilic chemotaxis and its secretions,[4] neutrophil inhibition, and inhibits cytokine release (interleukin [IL]-6, IL-1, IL-8, tumor necrosis factor). Both in combination act by suppressing antibody formation and modulation of the proinflammatory cytokine, and inhibits inflammatory cell accumulation and T-cell activation.[5] This case highlights the role of tetracycline and nicotinamide even in DH as an alternative when dapsone cannot be given. Only three similar cases have been reported, which warrants highlighting this overlooked aspect of management of DH.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salmi T, Hervonen K Current concepts of dermatitis herpetiformis. Acta Derm Venereol 2020;100:adv00056.  Back to cited text no. 1
    
2.
Bevans SL, Sami N Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis. Int J Dermatol 2017;56:e90-2.  Back to cited text no. 2
    
3.
Zemtsov A, Neldner KH Successful treatment of dermatitis herpetiformis with tetracycline and nicotinamide in a patient unable to tolerate dapsone. J Am Acad Dermatol 1993;28:505-6.  Back to cited text no. 3
    
4.
Shah SA, Ormerod AD Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide. Clin Exp Dermatol 2000;25:204-5.  Back to cited text no. 4
    
5.
Wang Y, Yang B, Zhou G, Zhang F Two cases of dermatitis herpetiformis successfully treated with tetracycline and niacinamide. Acta Dermatovenerol Croat 2018;26:273-5.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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