Dermatology Q32

Answer & Critique

Correct Answer: D

Educational Objective: Diagnose transient acantholytic dermatosis.

Key Point

Transient acantholytic dermatosis is characterized by red pruritic papules on the chest, flanks, and back associated with dry skin, heat, and sweating.

Transient acantholytic dermatosis, also known as Grover disease, is a benign common eruption that is most often seen in middle-aged to elderly men. The eruption presents as small discrete papules, some of which may be scaly, and papulovesicles on the trunk. Symptomatically there are varying degrees of pruritus. Although the cause and pathogenesis are unknown, a very common association is xerosis. The eruption is frequently triggered by excessive sweating. Skin biopsy shows acantholytic dyskeratosis. Transient acantholytic dermatosis is typically self-limited, but therapy with topical glucocorticoids or moisturizers may be effective.

Allergic contact dermatitis is a pruritic eruption of patches and plaques with variable vesiculation. The eruption is found in areas of allergen exposure and typically worsens with subsequent exposures. In exuberant cases, the localized inflammation can lead to a secondary “id” reaction, a generalized acute cutaneous reaction in which pinpoint flesh-colored to red papules develop diffusely on the body. The absence of a known sensitizer and a pruritic rash that is worsened with heat and sweating is not consistent with allergic contact dermatitis. Histologic studies show spongiotic dermatitis with eosinophils.

Although atopic dermatitis is pruritic and associated with xerosis, it is clinically distinguished from transient acantholytic dermatosis by the presence of scaly eczematous patches with variable degrees of lichenification. Also, atopic dermatitis in adults appears in the flexures of the extremities rather than the torso. Finally, the prevalence of atopic dermatitis decreases with age, whereas transient acantholytic dermatosis is more common in middle-aged to elderly men. On skin biopsy, there are variable degrees of spongiosis.

Lichen planus (LP) is characterized by pruritic, purple, polygonal papules that may coalesce into plaques characteristically involving the ankles and flexor surfaces of the wrist. Fine white lines may be visible on the surface of the papules or plaques. LP can also occur in the mucous membranes (mouth, vaginal vault, and penis) with white plaques that, if uncontrolled, may ulcerate. The eruption can also develop in the nails, leading to thickening and distortion of the nail plate. LP is most commonly idiopathic but may be induced by medications or possibly infection. The purple polygonal papules and plaques of LP are not consistent with this patient's rash. A skin biopsy shows lichenoid dermatitis.

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