Transient acantholytic dermatosis (Grover disease)

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Transient acantholytic dermatosis (Grover disease)

Murtaza Khan and John Berth-Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Grover disease is an acquired pruritic, papulovesicular eruption characterized histologically by focal acantholytic dyskeratosis. It is predominantly self-limiting. It is more common in middle-aged and elderly people, especially men, and involves mainly the trunk. The evolution is acute or chronic. The etiology is unknown, but excessive UV exposure, heat, sweating, and ionizing radiation are linked to the disease. Drugs, chemotherapeutic agents and cancers are also known triggers. Other skin disorders such as psoriasis or eczema of various types may coexist.

Management strategy

Grover disease is an uncommon disorder characterized by discrete erythematous, edematous papulovesicles or keratotic papules. The duration of the eruption may be weeks to months and it may be persistent or recurrent. Pruritus of variable intensity is experienced by most patients and may be out of proportion to the clinical signs. Constitutional symptoms are usually absent.

Treatment is difficult. There have been no large clinical trials and reports are based on small numbers.

Patients should be advised to avoid excessive sun exposure, strenuous exercise, heat, and occlusive fabrics. In mild cases, simple antipruritic measures such as avoidance of soap, simple emollients, and soothing baths with bath oils or colloidal oatmeal may be of benefit. Wet compresses with zinc oxide, calamine, or topical corticosteroids may help to relieve the itching.

Topical calcipotriol (ointment) twice daily 50 µg/g may be helpful after 3 to 4 weeks of treatment. Topical vitamin A acid (retinoic acid) is of limited use owing to skin irritation.

Systemic therapy may be indicated in more extensive and persistent disease. Oral vitamin A has been recommended in the past. The aromatic retinoid acitretin been used successfully in doses of 0.5 mg/kg daily. Isotretinoin 40 mg daily has been used for periods ranging from 2 to 12 weeks. It may be administered on a reducing regimen if the initial response is rapid, with a maintenance dose of 10 mg daily. Side effects include dry skin, cheilitis, teratogenicity, and elevation of cholesterol and triglycerides.

Systemic corticosteroids have been used to suppress inflammation and pruritus, but relapses frequently occur on drug withdrawal.

Psoralen with UVA (PUVA) may be useful, but an initial exacerbation may occur. There are anecdotal reports of the success of narrowband UVB and of medium-dose UVA1 phototherapy.

Topical 5-fluorouracil, dapsone, antibiotics, and cryotherapy are ineffective. Recently rituximab and etanercept have been reported to be useful.

First-line therapies

imageEmollients E
imageAvoid heat/sweating D
imageTopical corticosteroids D
imageAntihistamines D

Second-line therapies

imageIsotretinoin/acitretin D
imageSystemic corticosteroids D
imagePUVA E
imageVitamin A D

Third-line therapies

imageCalcipotriol E
imageTacalcitol E
imageTrichloroacetic acid E
imageUVA1 E
imageRituximab E
imageEtanercept E

Effective treatment of persistent Grover’s disease with tricholoroacetic acid peeling.

Kouba DJ, Dasgeb B, Deng AC, Gaspari AA. Dermatol Surg 2006; 32: 1083–8.

A 46-year-old woman had a 6-month history of progressive Grover disease with intractable pruritus. She failed to respond to topical calcipotriene (Dovonex). She was treated with an even, light application of 40% (w/v) TCA – single-pass strokes with TCA-dampened gauze. Individual lesions of Grover disease were identified and were re-treated with 40% TCA using a cotton-tipped applicator. Three weeks post procedure she had re-epithelialized and was disease free, and was still in remission 8 months later.

The authors stress that practitioners not accustomed to using TCA in office applications should use low-strength formulations such as 20–30% to avoid scarring.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Transient acantholytic dermatosis (Grover disease)

Murtaza Khan and John Berth-Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Grover disease is an acquired pruritic, papulovesicular eruption characterized histologically by focal acantholytic dyskeratosis. It is predominantly self-limiting. It is more common in middle-aged and elderly people, especially men, and involves mainly the trunk. The evolution is acute or chronic. The etiology is unknown, but excessive UV exposure, heat, sweating, and ionizing radiation are linked to the disease. Drugs, chemotherapeutic agents and cancers are also known triggers. Other skin disorders such as psoriasis or eczema of various types may coexist.

Management strategy

Grover disease is an uncommon disorder characterized by discrete erythematous, edematous papulovesicles or keratotic papules. The duration of the eruption may be weeks to months and it may be persistent or recurrent. Pruritus of variable intensity is experienced by most patients and may be out of proportion to the clinical signs. Constitutional symptoms are usually absent.

Treatment is difficult. There have been no large clinical trials and reports are based on small numbers.

Patients should be advised to avoid excessive sun exposure, strenuous exercise, heat, and occlusive fabrics. In mild cases, simple antipruritic measures such as avoidance of soap, simple emollients, and soothing baths with bath oils or colloidal oatmeal may be of benefit. Wet compresses with zinc oxide, calamine, or topical corticosteroids may help to relieve the itching.

Topical calcipotriol (ointment) twice daily 50 µg/g may be helpful after 3 to 4 weeks of treatment. Topical vitamin A acid (retinoic acid) is of limited use owing to skin irritation.

Systemic therapy may be indicated in more extensive and persistent disease. Oral vitamin A has been recommended in the past. The aromatic retinoid acitretin been used successfully in doses of 0.5 mg/kg daily. Isotretinoin 40 mg daily has been used for periods ranging from 2 to 12 weeks. It may be administered on a reducing regimen if the initial response is rapid, with a maintenance dose of 10 mg daily. Side effects include dry skin, cheilitis, teratogenicity, and elevation of cholesterol and triglycerides.

Systemic corticosteroids have been used to suppress inflammation and pruritus, but relapses frequently occur on drug withdrawal.

Psoralen with UVA (PUVA) may be useful, but an initial exacerbation may occur. There are anecdotal reports of the success of narrowband UVB and of medium-dose UVA1 phototherapy.

Topical 5-fluorouracil, dapsone, antibiotics, and cryotherapy are ineffective. Recently rituximab and etanercept have been reported to be useful.