How should I manage a middle‑aged to elderly man with transient acantholytic dermatosis (Grover’s disease) presenting with pruritic erythematous papules on the trunk?

Management of Grover's Disease (Transient Acantholytic Dermatosis)

First-Line Treatment: Topical Corticosteroids

Start with moderate- to high-potency topical corticosteroids applied 3-4 times daily for 2-4 weeks, as this achieves a 70% response rate and represents the most frequently employed and effective first-line therapy. 1

• Apply emollients with high lipid content at least twice daily to all affected areas, as xerotic skin and impaired epidermal barrier function are fundamental to Grover's disease pathogenesis 2, 3, 4
• Use hydrocortisone 2.5% or clobetasone butyrate for moderate cases, or clobetasol propionate for severe refractory lesions (though limit clobetasol to 2 consecutive weeks maximum and not exceeding 50g per week due to HPA axis suppression risk) 5, 6
• The disease occurs more commonly in winter against a backdrop of xerotic epidermis with decreased sweat production, contrary to the traditional belief that heat and sweating cause it 4

Systemic Therapy for Inadequate Response

If topical corticosteroids fail after 2-4 weeks, escalate to systemic retinoids (86% response rate) or systemic corticosteroids (64% response rate) as second-line options. 1

• Systemic retinoids demonstrate the highest response rate among all treatments and should be strongly considered for persistent cases 1
• Oral corticosteroids can achieve rapid resolution, as demonstrated in recent case reports 7
• The natural history shows spontaneous resolution in 42% of cases within one week to eight months, so treatment duration should be guided by clinical response 1

Symptomatic Management of Pruritus

Add non-sedating antihistamines for symptomatic relief of the characteristic intense pruritus:

• Fexofenadine 180 mg daily or loratadine 10 mg daily are safe choices, particularly in the typical elderly male demographic 2, 3
• Never use sedating antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) in elderly patients, as these increase fall risk, cause confusion, and may contribute to dementia 3, 5
• Consider gabapentin 100-300 mg at bedtime, titrating to 900-3600 mg daily as tolerated, for refractory pruritus after 2-4 weeks of topical therapy 3, 5

Skin Care Modifications

• Advise using mild soaps with neutral pH and warm (not hot) water, as the disease is associated with xerosis and impaired epidermal integrity 5, 4
• Avoid excessive bathing, harsh soaps, and synthetic fabrics that may worsen the condition 2, 5
• Keep nails short to minimize excoriation damage from scratching 5

Critical Diagnostic Considerations

The diagnosis requires both clinical and histopathologic confirmation:

• Typical presentation: pruritic erythematous papules and vesicles on the trunk of middle-aged to elderly men (mean age 59 years, male-to-female ratio 3.95:1) 1, 8
• Histopathology shows four different acantholytic patterns with suprabasal clefting, dyskeratotic cells (corps ronds and grains), and perivascular lymphocytic infiltrate 7, 8, 9
• Consider screening for SARS-CoV-2 infection in patients presenting with new-onset Grover-like eruptions, as recent reports document this association 7
• Examine for concurrent hematologic malignancies, as Grover's disease has been frequently associated with these conditions 8

Important Pitfalls to Avoid

• Do not use crotamiton cream (ineffective, Level B recommendation against use) 3, 5
• Avoid calamine lotion and topical capsaicin for this condition 2, 5
• Do not dismiss the diagnosis based on atypical distribution—rare monolateral blaschkoid variants have been reported, particularly following occlusive environments from bandages 9
• Recognize that the disease name "transient" is misleading, as many cases persist beyond the originally described temporary course 1, 8

Reassessment and Referral Criteria

• Reassess after 2-4 weeks of topical corticosteroid therapy 5, 1
• Refer to dermatology if no improvement after first-line therapy, if diagnostic uncertainty exists, or if skin biopsy is needed to confirm the diagnosis and exclude other acantholytic dermatoses like pemphigus or Darier's disease 2, 5, 9
• Consider internal medicine evaluation for associated systemic conditions, particularly hematologic malignancies 8