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A 50-year-old man presents with a 1-year history of an itchy, bumpy rash on his chest. He denies any history of similar rash and says there have been no “extraordinary changes” in his life that could have triggered this manifestation. Despite consulting various primary care providers, he has been unable to acquire either a definitive diagnosis or effective treatment.
The patient works exclusively in a climate-controlled office. Although there were no changes to laundry detergent, body soap, deodorant, or other products that might have precipitated the rash’s manifestation, he tried alternate products to see what effect they might have. Nothing beneficial came from these experiments. Similarly, the family dogs were temporarily “banished” with no improvement to his condition.
From the outset, the rash and the associated itching have been confined to the patient’s chest. No one else in his family is similarly affected.
The patient is otherwise quite well. He takes no prescription medications and denies any recent foreign travel.
EXAMINATION
The papulovesicular rash is strikingly uniform. The patient’s entire chest is covered with tiny vesicles, many with clear fluid inside. The lesions average 1.2 to 2 mm in width, and nearly all are quite palpable. Each lesion is slightly erythematous but neither warm nor tender on palpation.
Examination of the rest of the patient’s exposed skin reveals no similar lesions. His back, hands, and genitals are notably free of any such lesions.
A shave biopsy is performed, utilizing a saucerization technique, and the specimen is submitted to pathology for routine processing. The report confirms the papulovesicular nature of the lesions—but more significantly, it shows consistent acantholysis (loss of intracellular connections between keratinocytes), along with focal lymphohistiocytic infiltrates.
What’s the diagnosis?
DISCUSSION
This is a classic presentation of Grover disease, also known as transient acantholytic dermatosis (AD). While not rare, it is seen only occasionally in dermatology practices. When it does walk through the door, it is twice as likely to be seen in a male than in a female patient and less commonly seen in those with darker skin.
AD is easy enough to diagnose clinically, without biopsy, particularly in classic cases such as this one. The distribution and morphology of the rash, as well as the gender and age of the patient, are all typical of this idiopathic condition. The biopsy results, besides being consistent with AD, did serve to rule out other items in the differential (eg, bacterial folliculitis, pemphigus, and acne).
Since AD was first described in 1974 by R.W. Grover, MD, much research has been conducted to flesh out the nature of the disease, its potential causes, and possible treatment. One certainty about so-called transient AD is that most cases are far from transient—in fact, they can last for a year or more. Attempts have been made to connect AD with internal disease (eg, occult malignancy) or even mercury exposure, but these theories have not been corroborated.
Consistent treatment success has also been elusive. Most patients achieve decent relief with the use of topical steroid creams, with or without the addition of anti-inflammatory medications (eg, doxycycline). Other options include isotretinoin and psoralen plus ultraviolet A (PUVA) photochemotherapy. Fortunately, most cases eventually clear up.
TAKE-HOME LEARNING POINTS
- Grover disease, also known as transient acantholytic dermatosis (AD), usually manifests with an acute eruption of papulovesicular lesions.
- AD lesions tend to be confined to the chest and are typically pruritic.
- Clinical diagnosis is usually adequate, although biopsy, which will reveal typical findings of acantholysis, may be necessary to rule out other items in the differential.
- Treatment with topical steroids, oral doxycycline, and “tincture of time” usually suffices, but resolution may take a year or more.
A 50-year-old man presents with a 1-year history of an itchy, bumpy rash on his chest. He denies any history of similar rash and says there have been no “extraordinary changes” in his life that could have triggered this manifestation. Despite consulting various primary care providers, he has been unable to acquire either a definitive diagnosis or effective treatment.
The patient works exclusively in a climate-controlled office. Although there were no changes to laundry detergent, body soap, deodorant, or other products that might have precipitated the rash’s manifestation, he tried alternate products to see what effect they might have. Nothing beneficial came from these experiments. Similarly, the family dogs were temporarily “banished” with no improvement to his condition.
From the outset, the rash and the associated itching have been confined to the patient’s chest. No one else in his family is similarly affected.
The patient is otherwise quite well. He takes no prescription medications and denies any recent foreign travel.
EXAMINATION
The papulovesicular rash is strikingly uniform. The patient’s entire chest is covered with tiny vesicles, many with clear fluid inside. The lesions average 1.2 to 2 mm in width, and nearly all are quite palpable. Each lesion is slightly erythematous but neither warm nor tender on palpation.
Examination of the rest of the patient’s exposed skin reveals no similar lesions. His back, hands, and genitals are notably free of any such lesions.
A shave biopsy is performed, utilizing a saucerization technique, and the specimen is submitted to pathology for routine processing. The report confirms the papulovesicular nature of the lesions—but more significantly, it shows consistent acantholysis (loss of intracellular connections between keratinocytes), along with focal lymphohistiocytic infiltrates.
What’s the diagnosis?
DISCUSSION
This is a classic presentation of Grover disease, also known as transient acantholytic dermatosis (AD). While not rare, it is seen only occasionally in dermatology practices. When it does walk through the door, it is twice as likely to be seen in a male than in a female patient and less commonly seen in those with darker skin.
AD is easy enough to diagnose clinically, without biopsy, particularly in classic cases such as this one. The distribution and morphology of the rash, as well as the gender and age of the patient, are all typical of this idiopathic condition. The biopsy results, besides being consistent with AD, did serve to rule out other items in the differential (eg, bacterial folliculitis, pemphigus, and acne).
Since AD was first described in 1974 by R.W. Grover, MD, much research has been conducted to flesh out the nature of the disease, its potential causes, and possible treatment. One certainty about so-called transient AD is that most cases are far from transient—in fact, they can last for a year or more. Attempts have been made to connect AD with internal disease (eg, occult malignancy) or even mercury exposure, but these theories have not been corroborated.
Consistent treatment success has also been elusive. Most patients achieve decent relief with the use of topical steroid creams, with or without the addition of anti-inflammatory medications (eg, doxycycline). Other options include isotretinoin and psoralen plus ultraviolet A (PUVA) photochemotherapy. Fortunately, most cases eventually clear up.
TAKE-HOME LEARNING POINTS
- Grover disease, also known as transient acantholytic dermatosis (AD), usually manifests with an acute eruption of papulovesicular lesions.
- AD lesions tend to be confined to the chest and are typically pruritic.
- Clinical diagnosis is usually adequate, although biopsy, which will reveal typical findings of acantholysis, may be necessary to rule out other items in the differential.
- Treatment with topical steroids, oral doxycycline, and “tincture of time” usually suffices, but resolution may take a year or more.
A 50-year-old man presents with a 1-year history of an itchy, bumpy rash on his chest. He denies any history of similar rash and says there have been no “extraordinary changes” in his life that could have triggered this manifestation. Despite consulting various primary care providers, he has been unable to acquire either a definitive diagnosis or effective treatment.
The patient works exclusively in a climate-controlled office. Although there were no changes to laundry detergent, body soap, deodorant, or other products that might have precipitated the rash’s manifestation, he tried alternate products to see what effect they might have. Nothing beneficial came from these experiments. Similarly, the family dogs were temporarily “banished” with no improvement to his condition.
From the outset, the rash and the associated itching have been confined to the patient’s chest. No one else in his family is similarly affected.
The patient is otherwise quite well. He takes no prescription medications and denies any recent foreign travel.
EXAMINATION
The papulovesicular rash is strikingly uniform. The patient’s entire chest is covered with tiny vesicles, many with clear fluid inside. The lesions average 1.2 to 2 mm in width, and nearly all are quite palpable. Each lesion is slightly erythematous but neither warm nor tender on palpation.
Examination of the rest of the patient’s exposed skin reveals no similar lesions. His back, hands, and genitals are notably free of any such lesions.
A shave biopsy is performed, utilizing a saucerization technique, and the specimen is submitted to pathology for routine processing. The report confirms the papulovesicular nature of the lesions—but more significantly, it shows consistent acantholysis (loss of intracellular connections between keratinocytes), along with focal lymphohistiocytic infiltrates.
What’s the diagnosis?
DISCUSSION
This is a classic presentation of Grover disease, also known as transient acantholytic dermatosis (AD). While not rare, it is seen only occasionally in dermatology practices. When it does walk through the door, it is twice as likely to be seen in a male than in a female patient and less commonly seen in those with darker skin.
AD is easy enough to diagnose clinically, without biopsy, particularly in classic cases such as this one. The distribution and morphology of the rash, as well as the gender and age of the patient, are all typical of this idiopathic condition. The biopsy results, besides being consistent with AD, did serve to rule out other items in the differential (eg, bacterial folliculitis, pemphigus, and acne).
Since AD was first described in 1974 by R.W. Grover, MD, much research has been conducted to flesh out the nature of the disease, its potential causes, and possible treatment. One certainty about so-called transient AD is that most cases are far from transient—in fact, they can last for a year or more. Attempts have been made to connect AD with internal disease (eg, occult malignancy) or even mercury exposure, but these theories have not been corroborated.
Consistent treatment success has also been elusive. Most patients achieve decent relief with the use of topical steroid creams, with or without the addition of anti-inflammatory medications (eg, doxycycline). Other options include isotretinoin and psoralen plus ultraviolet A (PUVA) photochemotherapy. Fortunately, most cases eventually clear up.
TAKE-HOME LEARNING POINTS
- Grover disease, also known as transient acantholytic dermatosis (AD), usually manifests with an acute eruption of papulovesicular lesions.
- AD lesions tend to be confined to the chest and are typically pruritic.
- Clinical diagnosis is usually adequate, although biopsy, which will reveal typical findings of acantholysis, may be necessary to rule out other items in the differential.
- Treatment with topical steroids, oral doxycycline, and “tincture of time” usually suffices, but resolution may take a year or more.
