History:

A 32-year-old man consulted dermatology out-patient clinic for widespread severely pruritic skin rash involved the scalp, face, nape of the neck and neighbouring upper back, upper chest, pre-sacral region, lower abdomen and thighs. The itching was severe and paroxysmal and has greatly hindered the job and social life of the patient. On examination, multiple excoriated papulo-vesicles, erosions and even superficial ulcers grouped on erythematous bases were seen; however, on close examination many clear fluid-filled blisters on the back and lower abdomen were seen made the possibility of dermatitis herpetiformis as the provisional diagnosis. One vesicle was taken as biopsy and the patient was given Dapsone 100 mg tablet once daily for one week as a therapeutic and diagnostic trial. One week later, the patient had great symptomatic relief and the rash started to improve well. The biopsy showed sub-epidermal blister filled with neutrophils and some eosinophils in addition to papillary neutrophilic microabscesses. Unfortunately, direct immunofluorescence examination was unavailable.