Resident Dermatologist: Phil Milam, MD

Attending Dermatologist: Susan Massick, MD

Dermatopathologist: Catherine Chung, MD

HISTORY:

45 y.o. year old male presents with an extremely pruritic rash. He has had the rash since 2014 and noted that it seems to improve when he avoids gluten-rich foods. It originally started on his right eyebrow but has since spread to involve his neck, knees, and elbows.

On exam, the patient is noted to have symmetric papules and numerous excoriations (see figure).

Crusted excoriated papules on the elbows (left) and neck (right)

At low power, there is a subepidermal blister where the epidermis has separated from the dermis along the basement membrane zone.

Higher magnification demonstrates aggregates of neutrophils that fill the dermal papillae (i.e. “neutrophilic microabscesses” of the dermal papillae)

High power magnification demonstrate multilobular nuclei characteristic of neutrophils.

What is the most likely diagnosis?

  1. Dermatitis herpetiformis
  2. Herpes simples virus infection
  3. Linear IgA bullous dermatosis
  4. Scabies
Dermatitis herpetiformis