Case of the Month

Case of the Month

Grovers

50-year-old man presented with red, itchy bumps on the chest of approximate 6 months duration. He reports that they itch mildly, most of the time, but sometimes, with increased activity, they itch more.

He is otherwise healthy, taking no regular medicines (except a baby aspirin per day) and has an allergy to penicillin.

Here is a picture of the pathology:

Grovers
Photomicrograph courtesy of Erick Jacobson, MD, Dermatopathologist

What's Your Diagnosis?


Diagnosis:
Grover's Disease

Definition:
An inflammatory process characterized by a pruritic, papular, and uncommonly, a papulovesicular eruption of unknown cause affecting persons over 40 years of age (and usually over 60), often in photodistribution, but sometimes widespread. Although named originally “transient acantholytic dermatosis” by Grover, the condition usually persists for many months and even for years. The clinical presentation can be mild, i.e. a few scattered papules, to significant, as pictured below.

Grovers
Mild case of Grover's

Course:
Individual papular individual papules groomers disease may last for days they are smooth surfaced or weeks if they are keratotic. As has already been stated, although the disease was first designated transient and authentic dermatologist by Grover himself, and often last for months or years, rather than four weeks, as he originally thought. When, however, Grover's disease is induced by exposure to intense ultraviolet light, the lesions themselves, and the entire course of the disease may last for a little more than a week.

As an interesting aside, during residency I was taught that it was almost always seen in men. As I have practiced the past 18 years, I have seen many women (biopsy positive, see picture below) with the condition, although it is still much more common in men. One thing that I have noticed is that I have not ever seen Grover’s in a person of color, Fitzpatrick 4 or higher. Not sure why just an interesting observation.

Integration: Unifying Conept
Clinically, papules are the common denominator of Grover's disease, and, histopathologically, the common denominator of individual lesions is the presence within the epidermis of some acantholytic cells. The papules have either a smooth or keratotic surface. Those with a smooth surface show acantholytic cells in a pattern that stimulates those of Pemphigus Vulgaris, pemphigus foliaceous, Hailey-Hailey disease. Keratotic papules show changes that closely resemble those of Darier’s disease. Spongiosis may be an accompaniment of each of those histopathologic patterns. At times, more than one pattern may be seen in tissue sections of a single biopsy specimen of a lesion of Grover's disease.

The papules of Grover's disease are notoriously pruritic, and the most pruritic of all are those in which numerous eosinophils reside in the upper part of the dermis.

The cause of Grover's disease is not known.

Grovers in a woman
Grover's in a woman

Therapy:
Topical corticosteroids, local antipruritics, and systemic antihistamines may be helpful in alleviating the intractable pruritus. Retinoids given systemically have sent the eruption into remission and caused lesions in some patients to involute. In my experience reassurance is all that is needed for asymptomatic patients.

For patients with significant pruritus, I have had excellent success with triamcinolone o.1% cream applied twice daily for 2 weeks then once daily for 2-4 weeks combined with narrow-band UVB phototherapy for 4-6 weeks. Repeat series with flares, most (but not all) cases will resolve in 1-3 years.

Reference:

  1. A CLINICAL ATLAS OF 101 COMMON SKIN DISEASES
    With Histopathologic Correlation
    A. BERNARD ACKERMAN, HELMET KERL, JORGE SANCHEZ, YING GUO, ANGELIKA HOFER, PAUL KELLY, TETSU KIMURA, GIOVANNI BORRONI,CHARLES CRUTCHFIELD, VOLKER STEINKRAUS, WOLFGANG WEYERS
  2. Archives of Pathology Abstract

Charles Crutchfield III M.D. Eagan Dermatologist

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