One of my pet peeves is the way skin conditions are treated in this country. I cannot state what happens elsewhere, although I fear it’s similar, but here in the US dermatologists (skin doctors) tend to treat skin the way one would a stain on one’s shirt. In other words they direct all their attention to trying to make disappear, the rash, the dryness, the burning, etc. topically.
Why is that an error? The skin is an organ. In fact it’s our largest organ. It's also important to know that the skin is most closely related to the digestive tract, another very large and very important organ.
You Can Have 'Leaky Skin' in Addition to a 'Leaky Gut'
When we discuss celiac disease and gluten sensitivity, we often mention a leaky gut, a condition whereby the integrity and health of the small intestine is compromised. Interestingly, the skin can also be ‘leaky’ or too permeable. This problem actually explains why some people react to applying gluten topically while others do not – it depends on whether or not they have leaky skin.
There is a classic skin condition associated with gluten called dermatitis herpetiformis or DH. It is often knows as the celiac disease of the skin.
What is Dermatitis Herpetiformis (DH)?
DH appears as blisters in symmetrical areas of the body, including elbows, knees, buttocks, lower back and back of the head. The blisters are usually inflamed and red with severe burning and itching. The burning and itching can be present before a rash ever appears. I had one patient describe it as ‘lit kerosene beneath his skin’.
An immune substance called IgA, that is produced in the lining of the gut, is found as deposits in the skin of a DH patient. It is believed that gluten in the diet combines with IgA and together they enter the blood stream where they clog up small blood vessels in the skin. This manifestation creates an additional immune response by white blood cells and the result is the rash of DH.
Despite DH’s relationship to celiac disease, only 20% of patients suffering from it have any digestive symptoms. However, villous atrophy, the hallmark destruction of the small intestine consistent with celiac disease, is present 80% of the time. This ‘silent’ destruction likely contributes to the very few who are correctly diagnosed with DH. Instead they are given creams, lotions and steroids, all focusing on the rash itself instead of addressing the root cause of the condition – in this case dietary gluten consumption.
We know that DH exists and we know that it is the skin’s expression of the disease celiac. One would think that having that knowledge would be enough to appreciate that gluten can causes manifestations in areas beyond the digestive tract. But unfortunately we continue to hear of case after case whereby the patient had to diagnose themselves with celiac disease or gluten sensitivity when their doctor refused to test them because they had no or minimal digestive complaints.
The incidence of DH is thought to be 10 in 100,000 typically beginning in the 2nd to 4th decade of life. It is two times more common in men and more so in Caucasians of northern European descent. DH affects about 15%-25% of patients with celiac disease.
Skin Conditions Reflect Gut Health
In our practice we like to say that the skin is a reflection of gut health. Whether the condition is acne, eczema, dry skin, psoriasis or DH, when a skin condition is present we look to the gut. Researchers of DH agree with us. In fact they suggest that the tTG enzyme that is classically measured in the blood for celiac disease has a ‘skin derived’ version that indicates the presence of DH. They feel the underlying mechanism has to do with molecular mimicry between the gut’s tTG and the skin’s. By the way, Cyrex Labs is soon to release this particular skin-related tTG as a blood test for DH.
Treatment for DH is twofold:
1. Dapsone – a drug given for symptomatic relief that has a dangerous side effect of creating hemolytic anemia
2. Gluten-free diet
Why Are We Unsuccessful in Treating DH?
What’s the success rate? Full remission is only seen in 10-20% of patients. Not very good, I think you’ll agree.
Why does this occur? The patient and their doctor tend to focus solely on the appearance of the skin, rather than the state of health of the small intestine and body as a whole. When the skin “looks” better, patients cheat on their diet. It sounds ill advised and it is, especially considering that DH increases one’s risk of developing other autoimmune disease (thyroid, diabetes, etc) as well as small intestinal cancer.
But is it the patient’s fault? No, in my opinion it’s their doctor’s. Although with much good information available to pretty much everyone on the internet, I guess we can hold patients somewhat accountable. In the main, I think the brunt of the responsibility lies with the doctors who do not themselves know enough about DH and misdiagnose it as another condition or correctly diagnose it but then put no emphasis on healing the body as a whole.
Find the 'REAL' Root Cause of Your Skin Condition
If you or someone you know has a skin condition, regardless of whether it turns out to be DH, know this: The skin reflects the health of the digestive tract and with poor digestive health present, optimal health will be absent. Find a clinician who has the correct viewpoint of the body and who understands that skin conditions need to be treated by embracing the whole body , not topically.
Journal of European Academy of Dermatology and Venereology. 2009 Jun;23(6):633-8. Epub 2009 Mar 10.
“Guidelines for the diagnosis and treatment of dermatitis herpetiformis.”
World Journal of Gastroenterology 2007 April 14;13(14): 2138-2139
“Celiac disease and skin: Psoriasis association”
Journal of the American Academy of Dermatology. 2009 Jul;61(1):39-43.
“Autoantibodies against epidermal transglutaminase are sensitive dx marker in pts w/ DH on a normal or g-free diet.”
Clinical Gastroenterology and Hepatology. 2005 Apr;3(4):335-41.
“Permeability, zonulin production & enteropathy in DH.”