What is Grover’s disease

Grover’s disease also known as transient acantholytic dermatosis, is a skin condition that causes the sudden appearance of small, red spots on sun-damaged skin of the front and back of the upper chest and abdomen, most often in middle-aged and older white men and only rarely women ¹. These spots usually develop on the chest or back, but may also form on other parts of the body. Grover’s disease frequently leads to intense itching and the skin is fragile when scratched, although it may cause no symptoms. This can make the spots appear like small blisters or eroded areas. Most cases last six to twelve months even in immunocompromised patients (which is why it was originally called “transient”) ². Unfortunately it may last much longer. Occasionally, Grover’s disease may persist for longer periods, or it may come and go over time ³.

The exact cause of Grover’s disease is unknown; however, a number of factors may cause or worsen the condition including heat and sweating. The itchiness associated with Grover’s disease is frequently made worse by heat, humidity, sweating, tight clothing and more ultraviolet exposure. While there is no cure for Grover’s disease, there may be ways to manage the condition, such as avoidance of factors that worsen symptoms, moisturizers, and topical corticosteroids ⁴.

The prevalence (number of existing cases of a disease) and incidence (number of new cases over a period of time) have not been firmly established for Grover’s disease. In a study from Switzerland, Grover’s disease was diagnosed in 24 of more than 30,000 skin biopsies ⁴.

While generally accepted to be a benign, self-limited disorder, Grover’s disease is often persistent and difficult to manage; hence, the description of transient is misleading ⁵. The presentation can be subtle, or it may closely resemble other pruritic dermatoses. A high index of suspicion for this disease is necessary if the diagnosis is to be made correctly. Furthermore, the histologic features of transient acantholytic dermatosis (Grover disease) closely resemble those of several other conditions that are clinically distinct, which may add to potential diagnostic confusion.

What are the clinical features of Grover’s disease?

Grover’s disease often starts quite suddenly. It is more common in winter than in summer. Characteristics include:

• The most common sites are central back, mid chest.
• Lesions are small red, crusted or eroded papules.
• There may be vesicles and non-follicular pustules.
• Lesions may bleed.
• Although frequently itchy, Grover’s disease may cause no symptoms.

Grover’s disease may be complicated by the development of dermatitis, usually in a discoid pattern i.e with round or oval, dry or crusted plaques.

The plaques start on the chest and back, and may spread to affect other areas of the body.

Figure 1. Grover’s disease

[Source ⁶]

Figure 2. Grover’s disease

Is Grover’s disease contagious?

No, but the cause of Grover’s disease is still unclear and unknown.

Who gets Grover’s disease?

Grover’s disease most often affects men over 50. It is less common in women or younger people. It is common in those who are unwell in some way, but can arise in quite healthy people as well. It has been reported in association with several medications, including:

• Anastrozole
• Vemurafenib
• Dabrafenib
• Cetuximab
• Mercury
• D-penicillamine.

Grover’s disease cause

The exact cause of Grover’s disease is unknown; however, a number of factors may cause or worsen the condition including sunlight, excessive heat and profuse sweating, so there has been suspicion that it may relate to sweat or sweat ducts ⁷. But Grover’s disease also may arise in quite dry skin. Many affected individuals are sun damaged.

Researchers have variously linked Grover’s disease with prolonged fever, prolonged bed rest, excessive heat, and profuse sweating ⁸. The latter two features are assumed to derive from sweat ducts obstruction and from the leakage of products that induce acantholysis ⁹. However, the possibility still exists that smaller molecules may seep through the ductal epithelium and cause epidermal acantholysis ¹⁰. In addition, heat may directly cause acantholysis through the release of an unknown enzymatic factor after mild thermal injury ¹¹.

Solar damage is a common association ¹², but Grover’s disease has also been associated with drugs abuse, various malignancies, immunodeficiency conditions, including HIV infection, and bone marrow transplantation ¹³.

Grover’s disease was observed during chemotherapy treatment for neoplasia, especially after etoposide and ARA-C administration ¹⁴. Quite recently, a case of cetuximab-induced Grover’s disease was reported in an oncologic patient ¹⁵. No correlation whatsoever may be deduced between Grover’s disease and hematological disorder or chemotherapy.

The incidence of Grover’s disease in marrow transplant patients is about 1.8% ¹⁶, while a single exclusive case has been reported as occurring after renal transplantation ¹⁷. Although this association could be fortuitous, the fact that Grover’s disease often occurs in immunosuppressed patients suggests that immunosuppression could be a factor that favors the development of Grover’s disease ¹⁷.

Grover’s disease diagnosis

A dermatologist may make the diagnosis based on the clinical appearance of the skin and the symptoms. The individual usually feels well apart from their skin symptoms.

Sometimes a skin biopsy is needed to rule out other skin conditions that may resemble Grover’s Disease. The pathology of Grover’s disease is characteristic, with acantholysis (separated skin cells) with or without dyskeratosis (abnormal rounded skin cells). Spongiotic dermatitis may also be noted.

Grover’s disease treatment

There is no cure for Grover’s disease and treatment is usually based on a person’s symptoms. Affected individuals are usually advised to avoid strenuous exercise and excessive sun exposure, as sweating and heat may induce more itchy spots. Initial treatment options include topical steroid creams such as hydrocortisone, anti-itch lotions containing menthol or camphor, and calcipotriol cream. For more severe cases, options include tetracycline, isotretinoin, antifungal pills such as itraconazole, PUVA phototherapy, and cortisone (steroid) injections. These treatments have important side effects and may not be necessary for mild cases.

General measures

• Keep cool as sweating may induce more itchy spots. Wear garments designed to prevent sweat rash.
• Avoid predisposing factors such as heat, excessive sweating or sun exposure.
• Cooling emollients containing menthol and camphor can reduce the desire to scratch.

Topical treatment

• Steroid creams are often effective. Apply a mild topical steroid such as hydrocortisone, if possible as a lotion. It can be applied frequently to the affected areas to relieve itching.
• Similarly, calcipotriol cream may be helpful ¹⁸.

Systemic treatment is rarely required but may include the following:

• Antihistamines
• Systemic therapy includes oral vitamin A, corticosteroids, synthetic retinoids, and psoralen-PUVA ¹⁹. Oral retinoids such as acitretin or isotretinoin have been reported to be helpful, and may be required for several months. However, they have important side effects and are not necessary for mild cases.
• Phototherapy can be helpful, but may also provoke the disease.
• A course of tetracycline or an oral antifungal medication such as itraconazole helps some patients.
• Methotrexate and etanercept that also have been reported to help.

References

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