Abstracts & Literature Review 2

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Acupuncture and a gluten-free diet relieve urticaria and eczema in a
case of undiagnosed dermatitis herpetiformis and atypical or
extraintestinal celiac disease: a case report

Bahia A. Ohlsen DC, MS, MBA

JACO Editorial Reviewer:
I Donald S. Corenman, M.D., D.C., The Steadman Clinic

Published:

Journal of the Academy of Chiropractic Orthopedists
June 2015, Volume 12, Issue 2

The original article copyright belongs to the original publisher. This review is available from: http://www.dcorthoacademy.org © 2015 Corenman and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Author’s Abstract:

Objective: The purpose of this case report is to describe the use of acupuncture and a gluten- free diet (GFD) for urticaria and severe eczema in a patient with undiagnosed dermatitis herpetiformis and atypical or extraintestinal celiac disease.

Clinical Features: A 48-year-old woman presented with intense urticaria, eczema, worsening heartburn, chronic constipation, headaches, and an intense feeling of heat for 4 months. Results of punch biopsies of the skin lesions and laboratory tests were inconclusive. After the acupuncture sessions reported here ended, human leukocyte antigen blood typing revealed celiac disease and dermatitis herpetiformis–associated human leukocyte antigen DQ-8. Results of an endoscopy and colonoscopy were negative.

Intervention and Outcome: The patient received 3 acupuncture treatments a week for 12 weeks. The patient’s symptoms began in March 2008. She began using topical and oral steroids and felt that her symptoms were not responding. Acupuncture began in July 2008. At the end of the first 12 treatments, during which she was using topical and oral steroids, the urticaria and constipation resolved completely; and she had temporary relief from the heartburn. It is thought that the urticaria and constipation resolved because of the acupuncture as that was the only change. At the end of the second 12 treatments, during which time she had started Optifast, a GFD, the heartburn, headache, and eczema resolved. At the end of the third 12 treatments, all her symptoms remained resolved. Steroid treatment was discontinued after the first 12 treatments.

Conclusion: Acupuncture and diet changes appeared to provide relief from the urticaria and eczema of dermatitis herpetiformis beyond that obtained by traditional treatment of a GFD alone. © 2011 National University of Health Sciences.

JACO Editorial Summary

  • The article was written by Dr. Bahia A. Ohlsen, D.C., M.S., MBA of the Acupuncture and Yoga Center in Buffalo Grove, IL.
  • The purpose of this presentation is to demonstrate acupuncture and diet treatment in a case report of a patient with dermatitis herpetiform (DH) and “extraintestinal celiac disease”.
  • The investigator discusses the history, diagnosis and treatment of this patient and then goes into a good discussion of the immunology of this disorder (DH) and its relationship with celiac disease.
  • Celiac disease is a disorder of gluten metabolism. In these patients, the mucosal immune system of the small intestine is sensitive to gluten. Gluten exposure causes formation of antibodies called immunoglobulin A (IgA). This IgA then circulates in the bloodstream and deposits on the undersurface of the skin at the extensor surfaces (similar to the location of psoriasis). The rash is blistering and symmetrical.
  • This deposition of immunoglobulin is important as these proteins cross react with epidermal transglutimase. This reaction causes skin destruction and the typical purulent vesicular rash. These lesions look like herpes so the name dermatitis herpetiform is fitting. The difference is that herpes is typically unilateral and along one dermatome (herpes zoster or shingles).
  • A problem with this case report is that there is no control. That is, the patient had multiple forms of treatment so that no strong conclusion can be made regarding treatment effectiveness. When Dr. Ohlsen first started treatment, he reported, “The first 12 treatments with acupuncture were performed along with the use of topical steroid creams.”
  • This, of course, confuses the issue as two different treatments were afforded at the same time. There is nothing wrong with this and is standard medical care but two treatments at the same time dilute the potential efficacy of the treatment conclusions. However, if I understand the author correctly, the patient was already using topical creams when she started acupuncture treatments. If this is the case, a causal benefit can be considered with acupuncture.
  • Again, two different treatments were used at the same time after the first round of twelve acupuncture treatments. The patient had continued acupuncture and went on a gluten-free diet (“At the end of the second 12 treatments, during which time she had started Optifast, a GFD, the heartburn, headache, and eczema resolved”).
  • Since dermatitis herpetiform is considered a result of a gluten diet, no conclusions of the effectiveness of acupuncture can be made when the stimulant that causes the rash (gluten) is eliminated from the diet.
  • Another problem with this paper is that my understanding of dermatitis herpetiform requires a positive tissue biopsy necessary to make the diagnosis. There apparently were multiple tissue biopsies performed that were inconclusive. This does not mean that dermatitis herpetiform was not present but still questions the correct diagnosis. Nonetheless, the rash was treated successfully with the noted therapies so that the DH diagnosis is most likely the correct one.
  • Summary

    I commend Dr. Ohlsen for researching this disease process, presenting it with great care and understanding and successfully treating this patient. Dermatitis herpetiform and Celiac disease are two disorders that are commonly missed and the cause of distress for many patients. Since diet change is one of the best treatments for these two diseases, recognition and diet therapy are something we should be aware of. Dr. William Osler, the father of modern medicine stated it best when he said; “You see what you know and you find what you look for”. Let’s look for this disorder and treat it successfully.