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Seasonal variation of transient acantholytic dyskeratosis (Grover's disease)

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Background

Grover's disease (GD), or transient acantholytic dermatosis, is a pruritic, papulovesicular eruption characterized histopathologically by acantholysis with or without dyskeratosis. The origin of GD is unknown. Suggested causes include sweating, heat, immobilization occlusion, external beam and ultraviolet radiation, and xerosis. GD has also been found to occur in association with other diseases.

Objective

Our aim was to assess whether GD exhibits seasonal variation and, if so, to determine whether any inferences can be drawn from its seasonal variation regarding its cause.

Methods

We identified 385 patients who fulfilled both clinical and histopathologic criteria for GD among 423,106 patients diagnosed at the Ackerman Academy of Dermatopathology in New York City during the period from July 1, 1999 through June 30, 2004. By design, no hospitalized patients were studied.

Results

A diagnosis of GD was given to 0.09% of biopsy specimens at the Ackerman Academy of Dermatopathology. GD was diagnosed approximately 4 times more commonly in winter than in summer, although the number of biopsies was constant. The average age of GD patients was 64 years with a male/female ratio of 1.95:1. The most common histopathologic type of GD was pemphigus vulgaris. GD was suspected clinically in 54% of patients.

Limitations

This study did not assess hospitalized patients with GD or GD patients who lived outside the northeastern United States. Because the data assessed resided in a commercial dermatopathology laboratory, patients assessed in almost all cases had insurance coverage. Patients without insurance likely were not included in the study.

Conclusions

The diagnosis of GD constitutes a higher proportion of biopsies in the winter than in the summer and therefore, by inference, occurs more frequently in the winter. In the winter, elderly men whose skin is naturally xerotic sweat less and are exposed to low ambient humidity. Rather than being caused by sweating and heat, GD arises against a backdrop of an intact but xerotic epidermis with decreased sweat production and is likely related to impaired epidermal integrity.

Section snippets

Material and methods

A computerized search was performed to identify all patients in whom the diagnoses “transient acantholytic dermatosis,” “Grover's disease,” or “focal acantholytic dyskeratosis” were present in the pathology report, that is, in the clinical diagnosis, the histopathologic diagnosis, and/or a note appended to the histopathologic diagnosis, at the Ackerman Academy of Dermatopathology in New York City from July 1, 1999 through June 30, 2004. Of 423,106 patients we identified 660 patients with GD. We

Results

A total of 385 patients (255 men and 130 women [a sex ratio of 1.95:1; Table I]) with GD were identified. Three hundred sixty-eight patients (95.8%) lived in the northeastern United States and 17 lived elsewhere. We noted that GD occurred 4 times more often during the winter months (ie, January, February, March) than in the summer months (ie, June, July, August) (Fig 6). The percentage of GD biopsies as a percentage of total biopsies was highest in the winter, again by 4 to 5 times (Fig 7). In

Discussion

GD was first described in 6 patients by Ralph Grover in 1970. In 3 patients, he linked causally a sun induced Koebner phenomenon to transient acantholytic dermatosis. In 1984, Grover and Rosenbaum performed a retrospective study of 375 patients with GD. They noted that GD was most common in men older than 60 years of age and found a statistically significant association with atopic, asteatotic, or allergic contact dermatitis.7, 8 In 311 of 375 patients, Grover and Rosenbaum compiled the month

Conclusion

Our review suggested a relationship between GD and aged xerotic skin exposed to cold, dry winter air. Sun damage, radiation damage,36 and superficial skin infection similarly impaired epidermal integrity and provided settings conducive to the development of GD. Although the exact factors behind GD have yet to be fully defined, sweating and heat probably do not play a major role in its origin.

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    Funding sources: None.

    Conflicts of interest: None identified.

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