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Therapeutic Strategies

Grover's Disease/Transient Acantholytic Dermatosis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Overview

Lesions of transient acantholytic dermatosis (TAD) often are not "transient," and may persist for years. Heat and sweating appear to be triggers, with patients presenting after trips to tropical or semitropical climates, with fever, and after hospitalization or bedrest. Immunosuppression may increase the risk of developing TAD, as it is seen in patients with HIV infection, in leukemia, and in patients recently receiving bone marrow transplants. Pruritus may be severe. The strategy is to suppress the pruritus and if possible clear the cutaneous lesions.

First Steps

  1. If TAD is not pruritic, treatment may not be required.
  2. A high-potency or superpotent steroid cream, applied twice daily can be effective in some patients, and may suffice for patients with mild disease. Occlusion with a sauna suit may enhance therapy, although care must be taken to avoid overheating and sweating.
  3. Topical tretinoin gel 0.025% or tazarotene gel 0.05% or 0.1% applied once to twice daily may be effective. Often topical application must be continued to the point of irritancy for the lesions to resolve. Peeling should be anticipated.

Subsequent Steps

For patients with extensive or severely pruritic disease, begin low-dose isotretinoin 20-40 mg/day. Response may take more than a month. The dose can be tapered gradually as the condition improves; however, often 4-6 months of low-dose isotretinoin (10mg/day) may be required to induce a remission.

Alternative Steps

  1. Photochemotherapy (PUVA) is effective in some cases; an initial brief exacerbation may occur, however, before clearing.
  2. Systemic steroids can provide temporary relief, and can induce remissions. Relapses may occur. Systemic steroids should be reserved for the most severely pruritic patients, and an alternative treatment, as noted above, that will allow transition off the systemic steroids should be started if the systemic steroids are required for longer than 1 month in a dose exceeding 10 mg/day.

Ancillary Steps

  1. An emollient lotion containing menthol, phenol, and camphor may provide temporary relief.
  2. Antihistamines (e.g., doxepin 10-25 mg., hydroxyzine 10-50 mg, or diphenhydramine 25-50 mg as a single nightly dose) may help control the pruritus.
  3. Avoidance of sweating may prevent exacerbations.

Pitfalls

  1. TAD, despite its name, may not be transient, and may persist for years.
  2. The potential side effects of topical and systemic retinoids and topical steroids should be monitored.

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