DermDx: Red Itchy Rash on Chest

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A 62-year-old man presents with complaints of a red itchy rash affecting his chest and abdomen. The condition has been present for approximately 1 year and has waxed and waned in severity. He has been treated elsewhere for scabies on 2 separate occasions: the first with oral ivermectin and then with topical permethrin. Neither treatment afforded relief. The patient’s current medications included a statin and an angiotensin-converting enzyme (ACE) inhibitor. Physical examination reveals multiple erythematous papules some of which are covered with an adherent scale.

Grover disease, also known as transient acantholytic dermatosis, was first described in 1970 by Ralph Grover.1 This benign but oftentimes chronic condition most commonly occurs in White men in the fifth decade of life or later.2 It is characterized clinically...

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Grover disease, also known as transient acantholytic dermatosis, was first described in 1970 by Ralph Grover.1 This benign but oftentimes chronic condition most commonly occurs in White men in the fifth decade of life or later.2 It is characterized clinically by erythematous pruritic papules and occasional vesicles with frequent crusts and erosions.3,4 It primarily affects the upper trunk most notably on the chest and back.3,4 The disease often has a variable course with some cases resolving without treatment and others lasting for months or even years.5,6

Although the exact etiology and pathogenesis remain unknown, several triggers of disease activity have been reported. Worsening of symptoms has been associated with heat, excessive sweating, and exposure to UV light, with 1 theory suggesting that Grover disease is caused by sweat duct damage and occlusion.5 Underlying malignancy, chemotherapy, and organ transplantation have been associated with refractory cases.7 Several medications including BRAF inhibitors and immune checkpoint inhibitors have also been implicated in causality.8,9

Definitive diagnosis is achieved by skin biopsy. Four classical patterns have been described: Darier-like, Hailey-Hailey-like, Pemphigus-vulgaris-like, and spongiotic-like.3,5 Common features among these patterns include intraepidermal acantholysis (separation of skin cells) and varying degrees of dyskeratosis (abnormal rounding of skin cells).3,5

Grover disease requires differentiation from other skin conditions histologically characterized by acantholysis along with miliaria and folliculitis.5 Dermoscopy can aid in the diagnosis with findings of polygonal, star-like shaped yellowish/brownish structures containing polymorphous vessels on a pink background with a peripheral whitish halo.10,11

While called transient, the disease is often relapsing and can be chronic in nature.2,5 Management is centered on affording symptomatic relief and prevention of disease recurrence. Topical steroids and antihistamines are first-line therapies for pruritus.12 As heat and sweating may serve as triggers, patients should be advised to avoid activities leading to such exposures. Therapy with systemic retinoids, phototherapy, and systemic corticosteroids are usually reserved for treatment-resistant cases or extensive disease.5

Alexandra Stroia, BS, is a medical student at the Lake Erie College of Osteopathic Medicine. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

  1. Grover RW. Transient acantholytic dermatosis. Arch Dermatol. 1970;101((4)):426-434. 
  2. Bellinato F, Maurelli M, Gisondi P, Girolomoni G. Clinical features and treatments of transient acantholytic dermatosis (Grover’s disease): a systematic reviewJ Dtsch Dermatol Ges. 2020;18(8):826-833. doi:10.1111/ddg.14202
  3. Sousou JM, Fritsche JM, Fernandez BR, Tummala MR, Scott R. Management and treatment of grover’s disease: a case report and review of literatureCureus. 2022;14(4):e24082. doi:10.7759/cureus.24082
  4. Motaparthi K. Pseudoherpetic transient acantholytic dermatosis (Grover disease): case series and review of the literatureJ Cutan Pathol. 2017;44(5):486-489. doi:10.1111/cup.12909
  5. Aldana PC, Khachemoune A. Grover disease: review of subtypes with a focus on management optionsInt J Dermatol. 2020;59(5):543-550. doi:10.1111/ijd.14700
  6. Quirk CJ, Heenan PJ. Grover’s disease: 34 years onAustralas J Dermatol. 2004;45(2):83-88. doi:10.1111/j.1440-0960.2004.054_1.x
  7. Gantz M, Butler D, Goldberg M, Ryu J, McCalmont T, Shinkai K. Atypical features and systemic associations in extensive cases of Grover disease: a systematic reviewJ Am Acad Dermatol. 2017;77(5):952-957.e1. doi:10.1016/j.jaad.2017.06.041
  8. Carlos G, Anforth R, Clements A, et al. Cutaneous toxic effects of BRAF inhibitors alone and in combination with MEK inhibitors for metastatic melanomaJAMA Dermatol. 2015;151(10):1103-1109. doi:10.1001/jamadermatol.2015.1745
  9. Munoz J, Guillot B, Girard C, Dereure O, Du-Thanh A. First report of ipilimumab-induced Grover diseaseBr J Dermatol. 2014;171(5):1236-1237. doi:10.1111/bjd.13058
  10. Fink C, Toberer F, Haenssle HA. Dermoscopic characteristics of transient acantholytic dermatosis (Grover’s disease)Eur J Dermatol. 2017;27(6):648-650. doi:10.1684/ejd.2017.3104
  11. de Abreu L, Guimarães Cordeiro NG, Buçard AM, Quintella DC, Argenziano G. Dermoscopy of Grover diseaseJ Am Acad Dermatol. 2017;76(2S1):S60-S63. doi:10.1016/j.jaad.2016.07.031
  12. Vargas-Mora P, Orlandi D, Araya I, Morales C. Case for diagnosis. Atypical Grover’s diseaseAn Bras Dermatol. 2021;96(2):234-236. doi:10.1016/j.abd.2020.06.011

This article originally appeared on Clinical Advisor