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Grover’s Disease / Transient Acantholytic Dermatosis

Treatment

First-line therapy: The first-line therapy for Grover’s is to suppress pruritus and when possible, reduce inflammation and clear lesions.

First steps

  • If TAD is not pruritic, treatment may not be required.
  • A high-potency or superpotent steroid cream, such as fluocinonide 0.05% or clobetasol 0.05% 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.
  • 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 irritation in order for the lesions to resolve. Superficial desquamation should be anticipated.

Ancillary steps

  • 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.
  • Avoidance of sweating may prevent exacerbations.

Subsequent steps

  • Topical calcipotriene may also be helpful.
  • Photochemotherapy (PUVA) is effective in some cases; an initial brief exacerbation may occur, however, before clearing.
  • 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 (10 mg/day) may be required to induce a remission.
  • 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 one month in a dose exceeding 10 mg/day.
  • Other systemic therapies reported in the literature with potential efficacy for TAD include methotrexate, and etanercept.

Pitfalls

  • TAD, despite its name, may not be transient, and may persist for years.
  • Failure to improve with the suggested treatments should raise the consideration of secondary infection; infection of Grover’s disease with herpes simplex virus, Staphylococcus aureus, and scabietic infestation have been reported in the literature.
  • The important differential diagnosis of Darier’s disease and pemphigus foliaceus should be considered in unusual or extensive presentations.
  • The potential side effects of topical and systemic retinoids and topical steroids should be monitored.

When to refer to a dermatologist

  • When the diagnosis of Grover’s is not clear.
  • If pruritus associated with Grover’s cannot be mitigated.
  • If infection of Grover’s disease is suspected.
  • For persistent cases in which photochemotherapy may be helpful adjunctive treatment.