American Journal of Dermatopathology:
Letters to the Editor
Bearden, Jessica N. BS; Essary, Lydia R. MD; Cockerell, Clay J. MD
Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
Dermpath Diagnostics Cockerell and Associates, Dallas, Texas
Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
The authors have no conflicts of interest.
To the Editor:
Grover disease (GD) is an acquired usually self-limited disease that typically presents as a pruritic papulovesicular rash on the trunk and upper extremities. It is classically seen in older white males. First, described by Grover in 1970, the term transient acantholytic dermatosis became synonymous with GD given its sometimes fluctuant nature. However, persistent and recurrent forms have since been described.1 In 1 retrospective cohort study with follow-up of 28 patients with GD, 43% resolved, 46% recurred, and 11% persisted.2
Exacerbating factors typically include heat, exercise, sweating, and ultraviolet light. An increased frequency has also been described in bedridden and hospitalized patients; in a study of 72 cases of GD, 21% were noted to be confined to the bed.2 The occlusion of damaged eccrine ducts has been proposed as a mechanism for the development of GD; however, the pathogenesis remains largely unknown.
Acantholysis with dyskeratosis is the histological hallmark of the disease. A variation in features has led to 4 classically recognized patterns of acantholysis in GD: Darier like, Hailey–Hailey like, pemphigus like, and spongiotic. Additional patterns have been proposed recently, including porokeratotic, lentiginous, vesicular, lichenoid, and dysmaturative patterns.3 Recent literature also suggests that there may histopathologic changes distinct to early GD that may aid in early diagnosis, including elongation of rete ridges with acantholysis and eosinophils.4
A 48-year-old male presented with a pruritic papular eruption on his back occurring in episodes for 1 year (Fig. 1). The patient noted that the rash worsened with heat and exercise. He had been given a prior diagnosis of folliculitis; however, no improvement was noted with topical clindamycin. On exam, scattered 0.5- to 1-mm pink papules were present on the chest and back. Histopathologic study of a representative skin lesion on the left upper back showed focal acantholysis and dyskeratosis in the epithelium with concomitant foci of keratinocyte vacuolar degeneration with hypergranulosis of the stratum corneum and spinosum consistent with epidermolytic hyperkeratosis (EHK; Figs. 2, 3). The patient improved with Neostrata antibacterial cleanser and occasional Cordran cream use over the following month.
The biopsy in this patient demonstrated 2 distinct reaction patterns, namely that of focal acantholytic dyskeratosis consistent with GD and that of EHK. EHK denotes as not only a distinct histological pattern seen in generalized EHK (ichthyosis bullosa of Siemens) but also an incidental reaction pattern in a variety of conditions. These are numerous and include epithelial and melanocytic neoplasms, dermal fibrohistiocytic lesions, and inflammatory conditions. It can also be an incidental finding in otherwise normal-appearing skin.5 However, to our knowledge, there has not been a report in the literature of GD with coexistent features of EHK.
1. Weaver J, Bergfeld WF. Grover disease (transient acantholytic Dermatosis). Arch Pathol Lab Med. 2009; 133:1490–1494.
2. Davis MD, Dinneen AM, Landa N, et al. Grover’s disease: clinicopathologic review of 72 cases. Mayo Clin Proc. 1999; 74:229–234.
3. Fernandez-Figueras MT, Puig L, Cannata P, et al. Grover disease: a reappraisal of histopathological diagnostic criteria in 120 cases. Am J Dermatopathol. 2010; 32:541–548.
4. Melwani PM, Parsons AC, Sangueza OP. Early histopathologic changes in Grover disease. Am J Dermatopathol. 2010; 32:565–567.
5. Gaertner EM. Incidental cutaneous reaction patterns: epidermolytic hyperkeratosis, acantholytic dyskeratosis, and Hailey-Hailey-like acantholysis: a potential marker of premalignant skin change. J Skin Cancer. 2011; 2011:1–5.