Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
New or worsening itchy, blistering rash
Follow-up visit for dermatitis herpetiformis (DH)
II. History of Present Illness:
New rash:
Location and distribution of the rash (typically elbows, knees, buttocks, sacrum, lower back)
Appearance of the rash (clusters of small, itchy vesicles or bullae on erythematous base)
Duration of symptoms
Any associated burning or stinging sensation
Follow-up:
Response to treatment (improvement or worsening of rash)
Adherence to medication and gluten-free diet (if applicable)
III. Past Medical History:
Diagnosis of celiac disease (associated with DH in most cases)
Other skin conditions
IV. Family History:
Celiac disease in first-degree relatives (increased risk)
V. Medications:
Current medications (including medications for DH and celiac disease)
VI. Social History:
Diet (gluten intake)
VII. Physical Exam:
Vital signs (BP, HR, RR, Temp) – typically normal
Skin exam:
Distribution and appearance of the rash (as described in HPI)
Signs of excoriation (scratching)
Mucous membranes (may show aphthous ulcers in some cases)
VIII. Diagnostic Studies (consider as appropriate):
Skin biopsy with direct immunofluorescence (DIF): Gold standard for diagnosing DH, shows characteristic deposition of IgA in the dermal papillae.
Blood tests for celiac disease (if not already diagnosed): Tissue transglutaminase antibody (tTG-IgA), Deamidated gliadin peptide antibody (DGP-IgG)
IX. Assessment:
Dermatitis herpetiformis based on clinical presentation (itchy, blistering rash in characteristic locations) and positive DIF (if performed).
Activity level of DH (acute, chronic, controlled)
Presence of underlying celiac disease (based on history or blood tests)
X. Plan:
Treatment for DH:
Dap sulfone: First-line medication to control itching and blistering.
Topical corticosteroids: May be used for additional symptom relief.
Strict gluten-free diet: Essential for long-term management of DH and underlying celiac disease (if present).
Consider referral to a dietician for guidance.
Follow-up appointments for monitoring response to treatment and adherence to gluten-free diet.
XI. Prognosis:
DH can be effectively controlled with treatment, but lifelong adherence to a gluten-free diet is crucial.
Discuss the importance of identifying and managing any potential triggers (gluten exposure) to prevent flare-ups.
XII. Notes:
Address the patient’s concerns about the rash and the impact on quality of life.
Provide education on DH, celiac disease (if applicable), and the importance of gluten-free diet.
Emphasize the importance of regular follow-up to monitor disease activity and adjust treatment as needed.
XIII. Resources:
Consider providing patient education materials on dermatitis herpetiformis and celiac disease from reputable sources (e.g., American Academy of Dermatology, Celiac Disease Foundation).