Part 4 Of 12 Part Series: Skin Rashes, Hair, And Nail Symptoms In Undiagnosed Celiac Disease

This is the fourth in a series of posts discussing the variety of symptoms that can be caused by undiagnosed Celiac Disease (CD). In this post, skin rashes, hair, and nail symptoms will be discussed. In many with undiagnosed CD, the intestinal villi, responsible for absorbing nutrients, becomes damaged, creating a flattened mucosal surface (villous flattening) that is less able to absorb nutrients. Autoimmune reactions to ingested gluten cross-react with intestinal villi and create this damage. Various nutrient deficiencies can occur and this, along with inflammation and other autoimmune factors, can lead to various skin rashes, hair, and nail symptoms (1,2,3,4). 

Skin Rashes And Other Skin Symptoms

Dermatitis  Herpetiformis (Duhring’s Disease)

Dermatitis Herpetiformis (DH) occurs when autoimmune reactions lead to a skin rash. Unfortunately, this form of CD is often misdiagnosed as other various skin disorders and conditions (1). An individual with DH may be misdiagnosed with  psoriasis, poison ivy, pustular psoriasis, shingles, scabies, acne, acne rosea, hives, unexplained dermatitis herpes, recurrent mites, mosquito bites, flea bites, eczema and many other possible diagnosis that will be listed below (1,5,6). Symptoms include a blistering (papulovesicular eruptions) or scabbed rash that is very itchy. As well, the rash can have pimple type lesions or look similar to psoriasis with raised red patches of skin. In children, the rash may only present as purpura on the palms of their hands (in isolation or in addition to other symptoms). Usually the rash occurs bilaterally on the body and is commonly found on the buttocks, back, elbows, forearms, back of knees, scalp and on the face. Clinically, the rash can present anywhere on the body (1,5,6,7).

In the book “Dangerous Grains” it mentioned that there are dermatologists who continue to prescribe medication for Dermatitis Herpetiformis without prescribing a strict gluten-free diet. Unfortunately, these patients may continue to have a high risk of associated cancers, other autoimmune damage or malabsorption issues (even without bowel symptoms) with this approach (6). One Recreational Therapist that I worked with was diagnosed with DH and put on dapsone without being told about a gluten-free diet. The dermatologist did ask her if she had any bowel symptoms. She said no. Further tests were not completed and a gluten-free diet was not mentioned. Unfortunately, she suffered with side effects from the medication for 2 years with this approach. Following a discussion with me on a lunch break, she saw her MD, a gastroenterologist, and her dermatologist. She started a gluten-free diet and was able to discontinue the dapsone following a discussion with her doctor. Now, she is the picture of health, living rash and drug free. Dr. Peter Green, in his book, “Celiac disease” said, “If you have a positive diagnosis of dermatitis herpetiformis, you have celiac disease. And you must adhere to a gluten-free diet no matter how “normal” your intestine may appear.” (1)

Dr. Green also identified that the normal blood tests (endomysial antibodies and antitissue transglutaminase) for celiac disease might be negative in DH since they tend to correspond with the severity of intestinal damage in CD, not the severity of skin damage. Therefore, absence of intestinal damage could lead to negative CD blood tests. Dr. Green also identified that the unaffected skin beside (within millimeters) the lesion should be biopsied, not the lesion itself. Apparently, the inflammation in the lesion itself may make it difficult to see (in immunological staining) the initial immune factors responsible for DH. A skin biopsy that is positive for DH indicates that a strict gluten-free diet should be started, even with a negative intestinal biopsy (1). If the skin biopsy and intestinal biopsy are negative, but the rash appears to occur after gluten consumption (can be up to many days), then the biopsies should be repeated and and gluten sensitivities should be investigated. Rashes can result from food allergies or a gluten sensitivity in the absence of CD or DH (1,5,6,77,85).

Pictures of DH may be seen at http://tinyurl.com/qsge4v, http://tinyurl.com/l3s2fa, http://tinyurl.com/n3x4ls, or http://tinyurl.com/n9fo8x.

List Of Other Skin Rashes/Conditions Associated With Celiac Disease And Gluten Intolerance

• Cutaneous vasculitis (7,8-11)

• Hereditary Angioneurotic Edema (7,12-15)

• Urticaria (7,15-20,85)

• Linear IgA bullous dermatosis (7,21-25)

• Erythema nodosum (7,26-28)

• Necrolytic migratory erythema (7,29-32,85)

• Erythema elevatum diutinum (7,33-35)

• Psoriasis (7,36-44,78,85)

• Vitiligo (7,45-48,78)

• Behçet’s disease (7,49)

• Dermatomyositis (7,50-54,85)

• Porphyria  (7,55-57)

• Ichthyosiform dermatoses (7,58)

• Pellagra (7,59)

• Generalized acquired cutis laxa (7,60,61,85)

• Atypical mole syndrome and cogenital giant naevus (7,62-66)

• Prurigo nodularis (hyde’s prurigo) (71,85)

• Pityriasis rubra pilaris (72,85)

• Erythroderma (85)

• Acne (73)

• Acquired hypertrichosis lanuginosa (67)

• Ichthyosis (74,85)

• Transverse Leukonychia (85)

• Follicular Hyperkeratosis (78)

• Scleroderma (80)

• Sarcoidosis (28,78)

• Oral Lichen Planus (68-70)

• Bullous pemphigoid (85)

• Angular Cheilitis, glossitis, ulcerative stomatitis, and aphthous ulcers (78,79,85)

• Pale skin (from anemia) (78,79)

• Dry and/or cracked skin from dehydration and malabsorption of nutrients (80,81)

• Delayed wound healing (malabsorption of nutrients) (81,82)

• Edema (swollen skin) (78,79)

• Any itchy skin rashes (78)

• Melanoma (75)

• Dermatitis or acrodermatitis (78,79)

• IgA Linear dermatosis (85)

• Lupus erythematosus (85)

• Lichen sclerosous (85)

• Cutaneous amyloidosis (85)

• Annular erythema (85)

• Partial lipodystrophy (85)

• Atopic dermatitis (85)

• Palmoplantar pustulosis (85)

• seborrheic dermatitis-from riboflavin deficiency (81,82)

• Facial butterfly Rash-from niacin deficiency (81,82)

• Increased skin pigmentation (79)

• Spontaneous ecchymoses (78)

• Bruised skin (79)

• Purpura (79)

• Petechia (78)

• Bleeding under the skin (78)

I experienced generalized dry skin and cracked peeling skin on the heels of my feet. My lips would crack at the corners and I had canker sores in my mouth. Occasionally, intensely itchy red raised areas would occur on various parts of my body and I would get little pimples on my scalp. A butterfly rash would develop over my nose about once a week for awhile, then it would disappear for a month or two (lupus tests were negative). I was always pale, and I did tend to bruise easily. My mother, also with CD, bruised easily, was pale, had dry skin (especially on her feet), and would develop an unusual blotchy rash around her neck area. My daughter, at age 4 (also with CD), had red itchy patches that would last a few hours, then disappear. My mother and daughter did not have bowel symptoms. My bowel symptoms started after the birth of my first child.

My middle child tested negative for CD. She had eczema of moderate severity, hyperactivity, lack of focus, occasional diarrhea, and abdominal discomfort. All medical tests ordered by the paediatric allergist were negative. An elimination diet revealed that she was sensitive to corn and corn derivatives (which are in most grocery store products). All symptoms resolved when I removed corn from her diet. All symptoms return with accidental ingestion of corn.

Nutrient deficiencies partially or fully contributing to the above skin symptoms may include vitamin A, B complex, C, K, essential fatty and amino acids, iron, zinc, biotin,copper, and manganese (78,79,81,82).

Hair Symptoms

Alopecia Areata (Patches of hair loss) has been associated with CD . In CD, it may be the result of an immunological attack and/or nutrient deficiencies (1,7,79,81,82,83,84,85). Alopecia can be the only presenting symptom in CD (7).

An individual with CD may have dry, thin, brittle, slow growing hair due to nutrient deficiencies. Hair might change color due to malabsorption issues with pantothenic acid or manganese deficiencies (81,82).

My mother and I had hair that grew slowly, was fine, and brittle.

Nail Symptoms

Individuals with CD, may have nails that are dry, brittle, thin, malformed, and that break easily. This can be due to nutrient deficiencies or associated conditions. Nails may grow slowly and can also also have white bands, longitudinal striations, horizontal or vertical ridges, color changes, white spots, splinter hemorrhages, a deformed nail shape that is curved up or down (ex. spoon shaped with anemia), hang nails, or be clubbed. Muehrcke’s lines may indicate albumin levels are low. Beau’s lines can result from nutrient deficiencies disrupting nail growth, onycholysis can be associated with psoriasis or sarcoidosis, and the nails might be pitted (associated with psoriasis and alopecia). Telangiectasia may develop with underlying lupus, dermatomyositis, or scleroderma (86,87). Pictures and further description of these nail disorders can be found at http://tinyurl.com/lom4nt.

Nutrients Deficiencies that can contribute to nail abnormalities can include, vitamin A, B complex, C, K, protein, calcium, iron, and zinc (86).

I had nail symptoms including dry, brittle, nails that broke easily. Hang nails were continuously present and my nails frequently had white spots. My mother had horizontal ridges on her dry, brittle nails.

Do You Have Any Of The Above Symptoms?

Many individuals with undiagnosed CD will have no bowel symptoms (1,2,3,5,6,85). Weight loss may or may not occur, and is dependent on the amount of the intestine that is damaged (78). Therefore, the symptoms in this post could occur in the absence of weight loss or bowel symptoms.

The presence of skin, hair, or nail symptoms as discussed in this post, indicates that you should talk to your MD about tests for CD and tests to rule out other possible causes of your symptoms. Testing for CD is important because undiagnosed CD increases the risk of developing other autoimmune diseases, lymphomas (skin, brain, lymph nodes, intestine), cancers (thyroid, esophageal, mouth, tongue, pharynx, tonsil, and small intestine), allergies, complications from malabsorption issues, possible decreased immune response to other illnesses (1,78,79,88,89), and many other health complications that will be discussed in the posts about CD symptoms. It is my hope that if you have any of these symptoms you can print out this post complete with medical references to take with you to the MD when you request a CD test. Highlight or underline the sections that apply to your symptoms. I’ll be posting a simplified summary and checklist in the 12th post.

It is possible to have a gluten sensitivity even if you test negative for CD. It is also possible that your symptoms could be due to a food allergy/sensitivity or other disease process.  Allergy testing, and an elimination diet may help you to identify the offending food (5,6,77,85). Other tests can help rule out other diseases. I encourage everyone to have their symptoms thoroughly investigated by their MD and specialists before implementing a therapeutic diet. Keep your MD informed about any dietary changes you are making and also the results. Of course, I would love to hear your story as well.

I recommend waiting until CD testing is complete before initiating a gluten-free diet because it may create a false negative. Discuss this with your MD or specialist. USE CAUTION WITH SUPPLEMENTS. Toxicities can occur with over supplementation and this can lead to permanent damage. Consult your MD, Registered Dietitian, or other medical specialists involved in your care to determine which nutrients should be supplemented and to identify appropriate dosages for you. Review your symptoms and everything in this post with a Medical Doctor and your specialists before you make any changes. Your MD knows your medical history and the treatments that are appropriate for you.

Diagnosed Celiacs and people with food allergies/sensitivities, please comment about your symptoms  and experiences at the end of each post. This will help other readers to see how the sometimes illusive symptoms of CD or food sensitivities can affect each of us.  We are all unique!

References

1. Excellent Book: Green PHR, Jones, R. Celiac Disease A Hidden Epidemic. Collins, Harper Collins Publishers, 2006 http://tinyurl.com/ljeqjc

2. Pruessner Harold T, MD. Detecting Celiac Disease In Your Patients. American Family Physician. March 1st, 1998.

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5. Excellent Book: Lieberman Shari PhD,CNC, FACN, with Linda Segall. The Gluten Connection. How Gluten Sensitivity May Be Sabotaging Your Health. Rodale Inc., 2007. http://tinyurl.com/nwsc79

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