Case and Research Letters
Porokeratosis-Like Grover Disease: More Than an Acantholytic Pattern
Enfermedad de Grover tipo poroqueratósico: más allá de un patrón acantolítico
C. Montoya
, L.M. Arias, M. Salazar, H.A. Flórez
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Programa de Dermatopatología, Universidad CES, Medellín, Antioquia, Colombia
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Montoya, L.M. Arias, M. Salazar, H.A. Flórez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Montoya" "email" => array:1 [ 0 => "camilamontoyabueno@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L.M." "apellidos" => "Arias" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Salazar" ] 3 => array:2 [ "nombre" => "H.A." "apellidos" => "Flórez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Programa de Dermatopatología, Universidad CES, Medellín, Antioquia, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad de Grover tipo poroqueratósico: más allá de un patrón acantolítico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1332 "Ancho" => 1200 "Tamanyo" => 342374 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Panoramic image showing an oblique layer of parakeratosis on an acanthotic epidermis (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2). B, Enlarged image showing the epidermis with a central depression associated with an oblique column of parakeratosis and hypogranulosis (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">For many years Grover disease (GD) was classified as an acantholytic and transient dermatosis. It is now known that GD is not necessarily transient<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> and can give rise to several different histological patterns in addition to the 4 classical acantholytic patterns (Hailey-Hailey, Darier-like, spongiotic, and pemphigus-like).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> Forms of GD with nonclassical histological patterns described in recent years include dysmaturative, lichenoid, vesicular, and porokeratotic forms,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> a lentiginous form,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> and even a pseudoherpetic form.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> A common feature of all these forms is that acantholysis and dyskeratosis may not constitute the main clinical sign, may be focal, or may even be absent,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> complicating histological diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Importantly, in most cases these polymorphic histological findings are not associated with major clinical variability. Therefore, correlation of clinical and histological findings is fundamental, especially in early lesions, in order to establish an accurate diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 53-year-old man with no known underlying disease presented pruritic, papule-like lesions on the upper thorax, axillae (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and pubis that had appeared 10 years earlier. The lesions worsened in response to exposure to heat and sweating.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histology revealed the formation of a cornoid lamella with a column of parakeratosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), together with spongiosis, focal vacuolar damage, and erythrocyte extravasation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Nonspecific perivascular inflammatory infiltrate was evident in the dermis. A diagnosis of porokeratosis-like GD was established.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">GD was first described in 1970, and was associated with 2 distinct histological patterns: Darier-like and Hailey-Hailey-like.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In 1977, the same author described additional classic acantholytic patterns.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Subsequent studies investigated the clinical and epidemiological aspects of GD and described discrete clinical forms: transient; persistent, chronic, asymptomatic<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a>; and predominantly seasonal.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> In recent years, the histological characteristics initially proposed by Grover and Park in 1970<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> have been re-evaluated, and GD is now considered a polymorphic entity for which least 9 histological patterns are described. In their 2010 analysis of 22 cases, Melwani and coworkers described the lentiginous pattern as a diagnostic clue in cases of early GD.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> That same year, a review of 120 cases by Fernández-Figueras and coworkers added 5 histological subtypes to the 4 initially described by Grover et al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>: lentiginous, lichenoid, vesicular, dysmaturative, and porokeratotic.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Fernández-Figueras et al<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> described for the first time porokeratotic GD, an infrequent histological form of GD characterized by the formation of a cornoid lamella without epidermal hyperplasia, dyskeratosis, or acantholysis, in some cases associated with spongiosis and basal vacuolar damage, as observed in the present case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although parakeratotic columns had been previously described as a feature of Darier-type GD, associated with dyskeratosis, round bodies, and acantholysis,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,7</span></a> this finding had not been previously described in isolation. It should be borne in mind that while the presence of parakeratotic columns is a striking histological finding, it is not specific and is observed in several conditions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Porokeratosis-like GD is a rare entity: it accounted for less than 5% of cases in the case series by Fernández-Figueras et al,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> and few cases are reported in the literature.</p><p id="par0050" class="elsevierStylePara elsevierViewall">These unusual patterns can be difficult to recognize, since the alterations can be subtle, focally distributed, or combined.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2,4</span></a> For example, in our patient we observed areas with a spongiosis-like pattern and vacuolar damage in the basal layer, in addition to the porokeratotic-type pattern (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presence of these acantholytic and nonacantholytic patterns suggests that GD is a polymorphic entity that may be frequently underdiagnosed in daily practice.</p><p id="par0060" class="elsevierStylePara elsevierViewall">An interesting aspect of this case is that porokeratosis-like GD is an infrequent histological variant not characterized by the classical dyskeratotic and acantholytic changes.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The histological heterogeneity of GD has led to its inclusion in the differential diagnosis of multiple entities.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Awareness of the existence of nonclassical histological patterns can help avoid misinterpretation and unnecessary additional biopsies.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Clinicopathological correlation is essential to establish an accurate diagnosis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montoya C, Arias LM, Salazar M, Flórez HA. Enfermedad de Grover tipo poroqueratósico: más allá de un patrón acantolítico. Actas Dermosifiliogr. 2019;110:332–334.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 510 "Ancho" => 1250 "Tamanyo" => 97701 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythematous and crusted papules on the chest. B, Image showing erythematous papules in greater detail.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1332 "Ancho" => 1200 "Tamanyo" => 342374 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Panoramic image showing an oblique layer of parakeratosis on an acanthotic epidermis (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2). B, Enlarged image showing the epidermis with a central depression associated with an oblique column of parakeratosis and hypogranulosis (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 660 "Ancho" => 900 "Tamanyo" => 189506 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Acanthosis of the epidermis associated with spongiosis, erythrocyte extravasation, endothelial swelling, and vacuolar damage of the basal layer (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Keratosis lichenoides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pityriasis rubra pilaris \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grover disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fox-Fordyce disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Keratinization disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2026153.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nonporokeratotic Conditions Characterized by Cornoid Lamella.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Grover's disease: 34 years on" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.J. 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