Coeliac disease and dermatitis herpetiformis

Potential coeliac disease is characterised by the presence of serological and genetic markers of coeliac di-sease with little or no damage to the mucosa of the small intestine. Potential coeliac disease is a growing clinical entity, accounting for 10–20% of the total number of coeliac disease cases.In their excellent Seminar, Benjamin Lebwohl and colleagues do not give adequate attention to this increasingly observed disorder. Patients with potential coeliac disease can manifest with gastrointestinal or extraintestinal symptoms, or both, or be completely asymptomatic. Because villous atrophy is lacking in potential coeliac disease, whether a gluten-free diet should be recommended to patients is still a matter of debate. The scientific community suggests a gluten-free diet for patients with symptomatic potential coeliac disease, whereas asymptomatic patients are left on a gluten-containing diet and periodically followed up. With the aim of improving knowledge about potential coeliac disease, our research group has designed a (still ongoing) prospective cohort study and found that about 80% of adult patients with potential coeliac disease are symptomatic and benefit from gluten-free diet. Only 5% of the patients with asymptomatic potential coeliac disease left on a gluten-containing diet progress to active coeliac disease (ie, new onset of villous atrophy) in a median follow-up period of 7 years (mean 6·52 years, SD 3·54). On the basis of these results, we suggest a gluten-free diet for patients with symptomatic potential coeliac disease, whereas asymptomatic patients should be left on a gluten-containing diet. We would be delighted to learn what Lebwohl and colleagues think about the management of patients with potential coeliac disease.