What is the recommended initial treatment for an elderly male patient with Grover's disease?

Recommended Initial Treatment for Grover's Disease in an Elderly Male

Start with medium- to high-potency topical corticosteroids as first-line therapy, combined with antihistamines for pruritus relief and daily moisturizing emollients to address xerosis cutis. 1, 2

First-Line Treatment Approach

Topical Corticosteroids (Primary Therapy)

• Apply medium- to high-potency topical corticosteroids such as triamcinolone acetonide 0.1% cream or clobetasol propionate twice daily to affected areas. 1, 2, 3
• Topical corticosteroids demonstrate a 70% response rate in published case series and represent the most frequently employed treatment modality. 2
• Treatment duration typically ranges from 2-4 weeks, with clinical improvement often observed within the first two weeks. 4, 3

Adjunctive Symptomatic Management

• Add oral antihistamines (cetirizine, loratadine, or fexofenadine) for symptomatic relief of pruritus. 1, 5
• Apply moisturizing emollients at least once daily to address xerosis cutis, which is a recognized trigger for Grover's disease. 1, 4
• Avoid sedating antihistamines in elderly patients due to fall risk and cognitive effects. 5

Trigger Avoidance

• Counsel the patient to avoid excessive heat, sweating, and occlusive environments, as these are established precipitating factors. 4, 6
• Minimize ultraviolet radiation exposure, which can exacerbate the condition. 4
• Maintain skin hydration and avoid xerosis through regular emollient use. 1, 4

Conservative Management Option

• If lesions are asymptomatic and stable, observation with trigger avoidance and emollients alone may be sufficient. 1
• Spontaneous resolution occurs in approximately 42% of cases within one week to eight months without active treatment. 2

Second-Line Treatment Options (If First-Line Fails)

Systemic Therapies for Refractory Cases

• Systemic retinoids demonstrate an 86% response rate and should be considered for patients who fail topical corticosteroid therapy. 2
• Systemic corticosteroids show a 64% response rate and represent an alternative second-line option. 2
• These systemic options are reserved for persistent, widespread, or refractory disease after adequate trial of topical therapy. 2, 4

Important Clinical Considerations

Disease Course and Monitoring

• Grover's disease typically presents as pruritic papules and vesicle-papules on the trunk in middle-aged to elderly males (mean age 59 years). 2
• The condition may follow a transient course (resolving spontaneously), persistently pruritic pattern, or chronic asymptomatic course. 4
• Reassess after 2-4 weeks of topical therapy to determine treatment response. 5, 3

Special Considerations in Elderly Males

• This patient population has increased risk due to age-related xerosis and potential comorbidities. 2, 3
• Be vigilant for immunosuppression, malignancies, or other dermatologic conditions that may coexist with or trigger Grover's disease. 4, 7
• Consider underlying conditions such as renal insufficiency, which has been associated with Grover's disease. 4

Common Pitfalls to Avoid

• Do not use low-potency corticosteroids as initial therapy, as they demonstrate inferior efficacy for truncal lesions. 1, 2
• Avoid topical capsaicin or calamine lotion, which are not recommended for pruritus management in elderly patients. 5
• Do not delay biopsy confirmation if diagnosis is uncertain, as histopathologic examination showing acantholysis is essential for definitive diagnosis. 2, 7, 3