Large forehead: a novel sign of undiagnosed coeliac disease

The development of cranial proportions is the result of genetic, embriogenetic and environmental factors. Coeliac disease is a genetically inherited disease that is frequently diagnosed in adulthood in individuals, in whom the disease runs unidentified for years and can affect child growth from the moment of dietary gluten introduction up to the moment of gluten withdrawal following diagnosis. Data on the effects of gluten on craniofacial development in coeliac children are not available.

The aim of the present study is to evaluate gluten-related effects on face development in patients with undiagnosed coeliac disease and their clinical relevance.

The study was a prospective, multivariate analysis. Face photographs of adult patients with coeliac disease and healthy controls were marked at six reference points and distances and the ratios among distances were measured by computer program software.

The main finding of the study is that Caucasian Mediterranean adult coeliac individuals tend to have a peculiar aspect of the face characterised by a larger forehead when compared to general population controls.

The craniofacial morphology of patients with coeliac disease reveals an altered pattern of craniofacial growth. This is the first report of alterations of craniofacial development in coeliac disease. This alteration is a clinical sign that should be included among the extraintestinal manifestation of coeliac disease. It has a frequency comparable to other signs or symptoms such as anaemia and short stature and is a better predictor of coeliac disease than other signs such as recurrent aphthous stomatitis, recurrent abortion and dental enamel hypoplasia. A large forehead is a sign easily evident visually or with very simple measurements; computer analysis is not required for the general practitioner. This sign along with the presence of other clinical signs and symptoms, should alert a physician to test a patient for coeliac disease.