Extremely pruritic rash on the back and chest - Clinical Advisor

Extremely pruritic rash on the back and chest

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  • Grover Disease_1012 Derm Clinic

A woman, aged 64 years, presented with an itchy rash on her back and chest of several weeks’ duration. She reported that small red dots appeared on the middle of her back and spread to the rest of the back and the upper chest within a few days. The itching was intense at times, and the patient could not control herself from vigorously scratching.

No fever, malaise, or pain was reported. The woman had not started any new medications in the previous month. Physical exam revealed numerous discrete pink and red papulovesicles and erosions on the back and chest, along with scattered linear excoriations. The extremities, groin, and face were spared.




HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read White plaques in the oral cavity and Facial pustules after radiation treatment .

Transient acantholytic dermatosis is more commonly referred to as Grover disease. In 1970 Grover described a pruritic transient eruption in persons older than age 50 years. Although this condition is benign and eventually self-limiting, the rash tends to be persistent...

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Transient acantholytic dermatosis is more commonly referred to as Grover disease. In 1970 Grover described a pruritic transient eruption in persons older than age 50 years. Although this condition is benign and eventually self-limiting, the rash tends to be persistent and recurrent for months to a few years. For this reason, several authors suggest renaming the condition persistent and recurrent acantholytic dermatosis.1

The middle-aged and senior population is most commonly affected. In addition, whites appear to be affected at a significantly higher rate. Incidence is slightly greater in men than in women.

Clinical findings in Grover disease typically consist of numerous discrete 3- to 5-mm red, pink, or brown papules, papulovesicles, and erosions. On palpation, lesions may appear to be hyperkeratotic or verrucous. Although the central trunk is affected most often, lesions may infrequently be found on the proximal extremities. The palms, soles, and scalp are almost always spared.

Pruritus, usually of abrupt onset, is a hallmark of Grover disease. However, the severity of dermatitis is not always consistent with the severity of itching. While patients may report being unable to sleep because of the pruritus, few papules or erosions may be present on physical examination.

Diagnosis is usually clinical, but there is also a high rate of misdiagnosis, particularly in the nondermatologic setting. A high index of suspicion for this condition is often necessary to make the diagnosis. Biopsy may aid in the diagnosis, but because the histologic features of Grover disease are very similar to other conditions, clinical correlation is necessary.

The characteristic histopathologic finding in Grover disease is acantholysis (separation of keratinocytes in the epidermis), often in conjunction with varying degrees of spongiosis. Five distinct histologic findings exist and include findings simulating Darier disease, pemphigus vulgaris, pemphigus foliaceus, Hailey-Hailey disease (benign familial pemphigus), and spongiotic dermatitis.2 One biopsy specimen may contain several of these patterns.

Although Grover disease is often classified as a non­immune vesiculobullous disease, direct immunofluorescence findings are negative and nondiagnostic.

The differential diagnosis for papulovesicles and erosions on the trunk include dermatitis herpetiformis, herpes infection, arthropod assault, scabies, miliaria, syphilis, Darier disease, folliculitis, and drug eruption.

Although there is no known etiology, several factors have been suggested to contribute to the disease. Some studies reported an association between Grover disease and exposure to heat3 and excess sweating,4 as can often be seen in bedridden patients. Patients often describe a history of preceding sun exposure, heavy sweat-inducing exercise, or fever. Individuals with a history of atopic dermatitis are affected at a higher rate. A small number of cases have been described in association with lymphoma or other malignancies.

Treatment of Grover disease is aimed at reducing pruritus. Topical medium-potency corticosteroids are often the preferred treatment to reduce inflammation and relieve itching. Topical products containing menthol or pramoxine are also helpful. Oral antihistamines may be recommended, with the sedating variety reserved for nighttime use. In addition, hydroxyzine can be used as needed for itching. Oral steroids, oral retinoids,5 phototherapy, dapsone, and methotrexate (Rheumatrex, Trexall) are reserved for more severe and refractory cases.

Instruct patients to avoid extreme heat and activities that may cause excess sweating. Skin care should include use of emollients and avoidance of very hot or prolonged bathing. Education should include instructions regarding proper use of prescription medications and the risks associated with long-term use of topical corticosteroids. Advise patients that lesions may resolve with postinflammatory hyperpigmentation, and scarring may result from vigorous scratching.

Although Grover disease is usually a self-limiting disorder, some cases may persist or relapse intermittently. Many patients often return for frequent office visits to report that the rash is not resolving. For this reason, education regarding the chronic nature of the disease and natural history for spontaneous resolution will reassure many patients.

The patient in this case was educated regarding the chronic nature of her condition. Fluocinonide cream b.i.d. as needed for itching provided good relief. After three months, a significant decrease in the skin lesions was noted.

Esther Stern, NP-C, is a family practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.

References

  1. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: Saunders-Elsevier; 2011:478.
  2. Davis MD, Dinneen AM, Landa N, Gibson LE. Grover’s disease: clinicopathologic review of 72 cases. Mayo Clin Proc. 1999;74:229-234.
  3. Hu CH, Michel B, Farber EM. Transient acantholytic dermatosis (Grover’s disease). A skin disorder related to heat and sweating. Arch Dermatol. 1985;121:1439-1441.
  4. French LE, Piletta PA, Etienne A, et al. Incidence of transient acantholytic dermatosis (Grover’s disease) in a hospital setting. Dermatology. 1999;198:410-411.
  5. Helfman RJ. Grover’s disease treated with isotretinoin. Report of four cases. J Am Acad Dermatol. 1985;12:981-984.
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