Changing phenotype of celiac disease after long-term gluten exposure.

Celiac disease is an autoimmune disorder wherein the ingestion of gluten causes villous atrophy of the small intestinal mucosa with crypt hyperplasia in genetically susceptible individuals. The classic symptoms are malabsorption, steatorrhea, weight loss, growth retardation, and failure to thrive (1,2). Dermatitis herpetiformis is a well-known extraintestinal manifestation of celiac disease, characterized by granular immunoglobulin A (IgA) deposits in uninvolved skin (3). Approximately 17% of celiac patients have dermatitis herpetiformis (4). Celiac disease can appear at any age after gluten has been introduced into the diet, whereas dermatitis herpetiformis usually manifests in adulthood, the median age of diagnosis being about 40 years (4). It remains obscure why some patients experience celiac disease, overt enteropathy, and no skin involvement, whereas some experience dermatitis herpetiformis with often only mild enteropathy. The following 3 case reports indicate that periods of gluten intake and gluten withdrawal may have an impact on disease expression, and the phenotype may vary in the same person over time.