Related Therapeutic strategies

Herpes simplex virus (HSV) occurs in 2 common locations: orofacial (usually due to HSV-1) and genital (usually due to HSV-2).

Read more

Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma.

Read more

Chancroid

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of chancroid is usually clinical, although improved culture techniques allow isolation of the causative organism H. ducreyi. The therapeutic strategy is to eliminate the pathogenic microorganism.

Read more

Case Note

Case Note: Pruritic Eruption on the Torso

History

A 49-year-old healthy male, with past medical history of childhood eczema and allergic rhinitis, presents for management of pruritic eruption across the chest and back.

Initial evaluation

  • Very healthy-appearing Caucasian male
  • No significant past medical history besides childhood eczema and allergic rhinitis
  • Recently returned from 1-month hiking trip to Australia
  • Presents for management of severe pruritic eruption that started on his trip
    • Monomorphous erythematous crusted papules scattered across the chest and back
  • Denies any new cosmetic, plant, or insect exposures
  • Currently using diphenhydramine cream for relief of pruritus
  • Reports development of new lesions since returning from his trip
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of Grover's disease (transient acantholytic dermatosis [TAD]) is rendered

Initial Treatment

  • Fluocinonide 0.05% ointment once daily and frequent emollient use is recommended
  • A prescription of hydroxyzine 25-50 mg at bedtime is also given to suppress nocturnal pruritis
  • Patient counseled to avoid sweating and occlusion, when possible
  • Follow-up in 4 weeks

Follow-up evaluation strategy

4-week follow-up evaluation:

  • Fewer pruritic lesions but patient reports that lesions are ongoing
    • Patient admits to not using emollients
  • Ongoing fluocinonide ointment applied once daily and frequent emollient use is again recommended
    • Education on use of emollients is discussed and a handout on gentle skin care is given
  • Further follow-up in 4 weeks

Subsequent 4-week follow-up evaluation:

  • Patient is improved
  • Natural history of TAD is discussed as recurrences are common
  • The need for ongoing omollient use is reinforced

Further recommendations:

  • An emollient lotion containing menthol, phenol, and camphor may provide temporary relief
    • Thicker emollients are preferred, with caution for worsening of lesions due to occlusion by thick creams or ointments
  • Antihistamines (e.g. doxepin 10-25 mg, hydroxyzine 10-50 mg, or diphenhydramine 25-50 mg as a single evening dose) may help control the pruritus

Subsequent treatment steps:

  • Topical calcipotriene may be helpful
  • Photochemotherapy (PUVA) is effective in some cases
    • An initial brief exacerbation may occur, however, before clearing
  • For patients with extensive/severe pruritic disease:
    • Low-dose isotretinoin 20-40 mg/day
      • Response may take more than a month
      • Dose can be tapered as condition improves; however, often 4-6 months of low-dose isotretinoin (10 mg/day) may be required to induce a remission
    • Systemic steroids
      • Can provide temporary relief and induce remissions
      • Low-dose isotreinoin should be initiated if systemic steroids required for more than 1 month at a dose exceeding 10 mg/day
  • Methotrexate and etanercept have also been reported as being potentially efficacious for TAD

General discussion

Grover's disease, also known as TAD, is a common pruritic condition that typically affects adult individuals and classically presents on the trunk and proximal extremities. It may be more common in Caucasian individuals, especially in the fifth to seventh decades of life. The characteristic lesion is a crusted erythematous papule, pustule, or papulovesicle. Lesions of TAD are often not transient and may persist for years, especially in the inframammary regions. Biopsies of Grover's lesions may present across a broad histopathological spectrum, revealing acantholysis with spongiosis, Darier's disease-like features, pemphigus-like features, or Hailey-Hailey-like patterns.

Heat, sweating, and occlusion appear to be triggers, with patients presenting after trips to tropical or subtropical climates, after having fever, and after hospitalization or bed rest. Immunosuppression may increase the risk of developing TAD, as it is seen in patients with HIV infection, leukemia, and in patients recently receiving bone marrow transplants. History of extensive sun exposure and xerosis may also be important risk factors. Pruritis may be severe and the strategy is to suppress it and, if possible, to clear the cutaneous lesions. Gentle skin care and frequent emollient use may prevent recurrences.

Further reading

Gupta M, Huang V, Linette G, Cornelius L. Unusual complication of vemurafenib treatment of metastatic melanoma: exacerbation of acantholytic dyskeratosis complicated by Kaposi varicelliform eruption. JAAD 2012;148:966-8.

Norman R, Chau V. Use of etanercept in treating pruritus and preventing new lesions in Grover disease. JAAD 2011;64:796-8.

Quirk CJ, Heenan PJ. Grover's disease: 34 years on. Aust J Derm 2004;45:83-8.

CONTENT PROVIDED BY:
Derm101.com Logo

Disclaimer: The material above has been adapted from Therapeutic Strategies prepared by Derm101.com. It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.