Fifty seven children with dermatitis herpetiformis, 18 from Finland and 39 from 
Hungary, were studied. Diagnostic criteria included the finding of granular IgA 
deposits in the skin of all patients. The mean age at onset of the rash was 7 X 
2 years and favoured sites were the elbows, knees, and buttocks. Symptoms 
suggesting small intestinal disease were rare but in 35 (61%) of the children 
subtotal villous atrophy and in 16 (28%) partial villous atrophy were found on 
jejunal biopsy. Eighteen children underwent a second biopsy after a mean of 21 
months on a gluten free diet; villous height was found to be increased and the 
intraepithelial lymphocyte count decreased in all these patients. Gluten 
challenge caused a reversal in the two children who underwent a third biopsy. 
The effect of the gluten free diet on the rash was examined in Finnish children 
by observing the daily requirements of dapsone, a drug used to control the rash 
at the beginning of the diet. Eight (67%) of the 12 children were able to stop 
taking dapsone after a mean of 11 months on the diet and all three patients 
treated with diet alone became asymptomatic after three to 6 months on the diet. 
These results confirm that most children with dermatitis herpetiformis have 
jejunal villous atrophy, though they rarely have gastrointestinal symptoms. The 
central role of gluten in childhood dermatitis herpetiformis is evidenced by the 
fact that a gluten free diet helps the damaged jejunal mucosa to recover and 
controls the rash even in those children who do not have an abnormal jejunal 
biopsy.