What is the recommended treatment for a middle-aged to elderly individual diagnosed with Grover's disease?

Treatment of Grover's Disease

For middle-aged to elderly patients with Grover's disease, initiate treatment with medium-to-high potency topical corticosteroids (such as triamcinolone or clobetasol) applied twice daily, combined with oral antihistamines for pruritus and daily emollients to address xerosis cutis. 1

First-Line Therapy

Topical Corticosteroids

• Apply medium-to-high potency topical corticosteroids (triamcinolone, clobetasol) twice daily to affected areas as the primary treatment. 2, 1
• Topical corticosteroids demonstrate a 70% response rate in systematic reviews of Grover's disease treatment. 3
• Continue treatment for 4 weeks, then reassess for response. 4
• If lesions resolve, taper and discontinue topical steroids as clinically feasible. 2

Adjunctive Symptomatic Management

• Add oral antihistamines (cetirizine, loratadine, or fexofenadine) for symptomatic relief of pruritus. 1
• Apply moisturizing emollients at least once daily to address xerosis cutis, a recognized trigger for Grover's disease. 1, 4

Conservative Observation

• If lesions are asymptomatic and stable, conservative management with trigger avoidance and emollients alone may be sufficient without initiating corticosteroids. 1
• Spontaneous resolution occurs in 42% of cases within one week to eight months. 3

Second-Line Therapy for Refractory Cases

Systemic Retinoids

• For patients who fail to respond to 4-6 weeks of topical corticosteroids, initiate oral isotretinoin as second-line therapy. 3, 5
• Systemic retinoids demonstrate an 86% response rate in published case series. 3
• Three of four patients with relatively acute disease achieved remissions lasting up to 10 months after isotretinoin treatment. 5

Systemic Corticosteroids

• Oral corticosteroids represent an alternative second-line option with a 64% response rate. 3
• Reserve for patients with extensive, severely pruritic disease who cannot tolerate or fail retinoid therapy. 3

Additional Treatment Options for Resistant Disease

Phototherapy

• PUVA (psoralen plus ultraviolet A) phototherapy can suppress symptoms in resistant cases. 6
• Consider when both topical and systemic therapies have failed. 6

Other Systemic Agents

• Methotrexate may be considered for highly resistant cases, though evidence is limited to case reports. 3
• Acitretin represents an alternative retinoid option with documented efficacy. 6

Critical Management Considerations

Trigger Avoidance

• Counsel patients to avoid excessive heat, sweating, and prolonged bed rest, as these exacerbate disease. 4, 6
• Minimize ultraviolet radiation exposure, particularly in patients with sun-damaged skin or history of actinic keratosis. 4
• Maintain cool, dry environments, as the disease is four times more likely to flare in winter months due to xerosis. 4

Special Populations

• In immunosuppressed patients (transplant recipients, HIV, hemodialysis), Grover's disease may present atypically and persist longer. 4
• Lesions in transplant recipients may resolve spontaneously within 2 weeks to several months even without treatment modification. 4

Expected Disease Course

• Typical duration ranges from several weeks to months, though chronic cases lasting years occur, particularly in hemodialysis patients. 4, 6
• The disease characteristically waxes and wanes over time. 7

Common Pitfalls

• Do not continue ineffective topical corticosteroid therapy beyond 4-6 weeks; escalate to systemic therapy promptly. 4, 3
• Recognize that histological patterns (Darier-like, pemphigus vulgaris-like, Hailey-Hailey-like, or spongiotic) do not predict treatment response and should not guide therapy selection. 4
• Be aware that bullous variants exist and may initially be mistaken for folliculitis, contact dermatitis, or viral infections. 7