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Case for diagnosis.
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PMID:  23197221     Owner:  NLM     Status:  In-Data-Review    
We report a clinical case of a rare variant of pemphigus - pemphigus herpetiformis - which combines the clinical features of dermatitis herpetiformis with the immunological findings of pemphigus. Due to its atypical presentation, it is frequently misdiagnosed as dermatitis herpetiformis. It is basically characterized by the herpetiform pattern of skin lesions, severe pruritus and by the presence of eosinophilic spongiosis confirmed on histopathology. We call attention to the excellent response to dapsone.
Iolanda Conde Fernandes; Madalena Sanches; Rosário Alves; Manuela Selores
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Anais brasileiros de dermatologia     Volume:  87     ISSN:  1806-4841     ISO Abbreviation:  An Bras Dermatol     Publication Date:  2012 Dec 
Date Detail:
Created Date:  2012-11-30     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0067662     Medline TA:  An Bras Dermatol     Country:  Brazil    
Other Details:
Languages:  eng     Pagination:  933-5     Citation Subset:  IM    
Service of Dermatology, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
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Journal Information
Journal ID (nlm-ta): An Bras Dermatol
Journal ID (iso-abbrev): An Bras Dermatol
Journal ID (publisher-id): An. bras. dermatol.
ISSN: 0365-0596
ISSN: 1806-4841
Publisher: Sociedade Brasileira de Dermatologia
Article Information
Download PDF©2012 by Anais Brasileiros de Dermatologia
Received Day: 14 Month: 6 Year: 2011
Accepted Day: 02 Month: 1 Year: 2012
Print publication date: Season: Nov-Dec Year: 2012
Volume: 87 Issue: 6
First Page: 933 Last Page: 935
PubMed Id: 23197221
ID: 3699924
DOI: 10.1590/S0365-05962012000600023

Case for diagnosis*
Iolanda Conde Fernandes1
Madalena Sanches2
Rosário Alves3
Manuela Selores4
1Resident in Dermatology - Service of Dermatology, Centro Hospitalar do Porto (Porto Hospital Center), EPE - Hospital de Santo António (Santo António Hospital) - Porto, Portugal
2Head of the Service of Dermatology - Centro Hospitalar do Porto, EPE - Hospital de Santo António - Porto, Portugal
3Physician Assistant, Department of Dermatology - Service of Dermatology, Centro Hospitalar do Porto, EPE - Hospital de Santo António - Porto, Portugal
4Director of the Department of Dermatology, Professor of Dermatology (School of Biomedicine) - Head of the Department - Service of Dermatology, Centro Hospitalar do Porto, EPE - Hospital de Santo António - Porto, Portugal
Correspondence: Mailing address: Iolanda Conde Fernandes, Edifício das consultas Externas, Ex-CICAP, Rua D. Manuel II, s/n, Porto. Portugal - 4100, E-mail:


A 63-year-old Caucasian man presented with a two-month history of an intensely pruritic, symmetric and polymorphous skin eruption. His past medical history was unremarkable.

On examination, we observed multiple papules, vesicles, pustules and crusted excoriations on an erythematous base, especially over the buttocks, legs and arms (Figure 1). The oral and genital mucosas were spared. Nikolsky's sign was negative.

Tzanck smear showed abundant eosinophils with absence of acantholytic cells. Histopathological examination revealed eosinophilic spongiosis and intraepidermal vesicles filled with eosinophils and neutrophils (Figure 2). Direct immunofluorescence microscopy showed intercellular deposits of IgG (Figure 3). High titers of circulating anti-desmoglein 1 autoantibodies were demonstrated by immunoblot study. The remaining workup, which included blood tests, imagiologic studies and gastrointestinal endoscopy, was normal.

The patient was treated with 100 mg/day dapsone and showed an excellent response. After a year, he was free of the disease on a maintenance dose of 50 mg dapsone daily.


Pemphigus herpetiformis (PH) was diagnosed based on clinical, histopathological and immunological findings.

PH was first introduced by Jablonska et al. in 1975. 1 It is considered a rare variant of pemphigus which combines the clinical features of dermatitis herpetiformis with the immunological findings of pemphigus. Due to its rarity and atypical presentation, PH is frequently misdiagnosed as dermatitis herpetiformis, pemphigus foliaceus, bullous pemphigoid and several other autoimmune bullous conditions.

Clinically, patients present with severe intractable pruritus with cutaneous lesions arranged in a herpetiform pattern, resembling the clinical picture of dermatitis herpetiformis. Histological findings vary according to the evolution of skin lesions, and typical findings of pemphigus emerge only later in the disease process. 2 Therefore, several biopsies may be needed to establish a correct diagnosis. In the early stages, biopsy specimens show eosinophilic spongiosis with or without acantholytic cells and intraepidermal vesicles and bullae filled with neutrophils and eosinophils. This is an important but non-diagnostic histological reaction and it may be the initial pattern of a pre-acantholytic inflammatory stage. The finding of eosinophilic spongiosis should prompt a recommendation for other diagnostic studies. Because the clinical presentation of the disease and the histological findings are often atypical, the most consistent test for diagnosis of PH is immunofluorescence. 3 Direct immunofluorescence (DIF) performed on perilesional skin revealed intraepithelial intercellular IgG deposits, which is the typical finding. 3 Most PH autoantibodies target desmoglein (Dsg) 1, with exceptional cases manifesting autoantibodies against Dsg 3, implicating the predominant autoimmunity similar to pemphigus foliaceus rather than pemphigus vulgaris. 4 Several cases of PH without anti-Dsg 1-3 autoantibodies were reported. 4 More recently, it has been found that many patients with PH also show autoantibodies against desmocollin. 5

Several papers have reported clinical cases of HP associated with some neoplasms, HIV infection and medication. 6,7,8 Diagnostic investigations in our patient showed no evidence of associated systemic disease, and he was not taking any drugs.

In general, the disease shows a benign course, with a good response to treatment. Our patient had been initially treated with prednisolone without any benefit. Therefore, he was started on dapsone with total response. Dapsone is considered the best drug for the treatment of PH with doses ranging from 100 to 300 mg daily. 2 It may be given as monotherapy or in association with corticosteroids and immunosuppressant drugs. It is known that superficial forms of pemphigus, those with low or negative antibody titers and histological features of eosinophilic spongiosis, respond well to dapsone. 9 However, some cases of PF and PV in patients with PH have been reported. 2,9 In these cases, systemic corticosteroids in combination with immunosuppressants may be required.


Conflict of interest: None

Financial funding: None

fn01* Work conducted at Centro Hospitalar do Porto, EPE - Hospital Geral de Santo António - Porto, Portugal.

1. Jablonska S,Chorzelski TP,Beutner EH,Chorzelska J. Herpetiform pemphigus, a variable pattern of pemphigusInt J DermatolYear: 1975143533591097347
2. Robinson ND,Hashimoto T,Amagai M,Chan LS. The new pemphigus variantsJ Am Acad DermatolYear: 19994064967110321591
3. Aoki V,Sousa JX Jr,Fukumori LM,Périgo AM,Freitas EL,Oliveira ZN. Imunofluorescência direta e indiretaAn Bras DermatolYear: 20108549050020944909
4. Miura T,Kawakami Y,Oyama N,Ohtsuka M,Suzuki Y,Ohyama B,et al. A case of pemphigus herpetiformis with absence of antibodies to desmogleins 1 and 3J Eur Dermatol VenereolYear: 201024101103
5. Tateishi C,Tsuruta D,Nakanishi T,Uehara S,Kobayashi H,Ishii M,et al. Antidesmocollin-1 antibody-positive, antidesmoglein antibody-negative pemphigus herpetiformisJ Am Acad DermatolYear: 201063
6. Prado R,Brice SL,Fukuda S,Hashimoto T,Fujita M. Paraneoplastic pemphigus herpetiformis with IgG antibodies to desmoglein 3 and without mucosal lesionsArch DermatolYear: 2011147677121242397
7. Bull RH,Fallowfield ME,Marsden RA. Autoimmune blistering diseases associated with HIV infectionClin Exp DermatolYear: 19941947508313636
8. Verdier-Sevrain S,Joly P,Thomine E,Belanyl PH,Gilbert D,Tron F,et al. Thiopronine-induced herpetiform pemphigus: report of a case studied by immunoelectron microscopy and immunoblot analysisBr J DermatolYear: 19941302382408123578
9. Dias M,dos Santos AP,Sousa J,Maya M. Herpetiform pemphigusJ Eur Acad Dermatol VenereolYear: 199912828510188168


[Figure ID: f01]

Clinical features showing multiple papules, vesicles, pustules and crusted excoriations on an erythematous base over the buttocks

[Figure ID: f02]

Histopathological examination revealing eosinophilic spongiosis and intraepidermal vesicles filled with eosinophils and neutrophils (Hematoxylin and Eosin staining 40x)

[Figure ID: f03]

Direct immunofluorescence performed on perilesional skin revealing IgG deposits at the keratinocyte cell surface

Article Categories:
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Keywords: Biopsy, Dapsone, Fluorescent antibody technique, Pemphigus.

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