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Clinical Cases in Pruritus Guidelines

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Chapter 1 72-Year-Old Male with Itchy, Erythematous Papules on His Trunk Amy Mehlman, Austin Cusick, and Shannon C. Trotter A 72-year-old male presented with itchy, erythematous papules on his trunk, most concentrated in the middle of his chest and back. The eruption had been present for 6 mo...

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clinical cases in pruritus
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Clinical Cases in Dermatology
Series Editor: Robert A. Norman

Shannon C. Trotter
Austin Cusick Editors

Clinical Cases
in Pruritus

,Clinical Cases in Dermatology
Series Editor
Robert A. Norman
Tampa, FL, USA

,This series of concise practical guides is designed to facilitate the clinical decision-
making process by reviewing a number of cases and defining the various diagnostic
and management decisions open to clinicians.
Each title is illustrated and diverse in scope, enabling the reader to obtain relevant
clinical information regarding both standard and unusual cases in a rapid, easy to
digest format. Each focuses on one disease or patient group, and includes common
cases to allow readers to know they are doing things right if they follow the case
guidelines.

More information about this series at http://www.springer.com/series/10473

,Shannon C. Trotter • Austin Cusick
Editors

Clinical Cases in Pruritus

,Editors
Shannon C. Trotter Austin Cusick
Ohio University Heritage College of Ohio University Heritage College
Osteopathic Medicine of Osteopathic Medicine
Athens, OH Athens, GA
USA USA
Dermatologists of Central States
Canal Winchester, OH
USA

ISSN 2730-6178 ISSN 2730-6186 (electronic)
Clinical Cases in Dermatology
ISBN 978-3-030-66273-8 ISBN 978-3-030-66274-5 (eBook)
https://doi.org/10.1007/978-3-030-66274-5

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

,Contents

1 72-Year-Old Male with Itchy, Erythematous
Papules on His Trunk�� 1
Amy Mehlman, Austin Cusick, and Shannon C. Trotter
2 80-Year-Old Female with Itchy Hives and Bullae on the
Trunk and Extremities�� 7
Kassandra Riggs, Austin Cusick, and Shannon C. Trotter
3 20-Year-Old Female with Diffuse Itchy, Scaly Skin�� 13
Erica Haught, Austin Cusick, and Shannon C. Trotter
4 33-Year-Old Male with Itchy, Erythematous
Papules on His Trunk�� 21
Amy Mehlman, Austin Cusick, and Shannon C. Trotter
5 55-Year-Old Female with Itchy, Erythematous,
Scaly Plaques on the Trunk�� 27
Mara Leyendecker, Pankaj Bansal, Austin Cusick,
and Shannon C. Trotter
6 40-Year-Old Female with Itchy, Erythematous
Papules and Nodules on the Trunk and Extremities�� 37
Rosemary Oaks, Austin Cusick, and Shannon C. Trotter
7 63-Year-Old Female with a Persistent Itchy
Patch on the Shoulder Blade�� 43
Daniel A. Hyman, Austin Cusick, and Shannon C. Trotter
8 56-Year-Old Male with Itchy Bilateral Forearms �� 49
Daniel A. Hyman, Austin Cusick, and Shannon C. Trotter
9 68-Year-Old Male with Intense Itching
Followed by Blisters on the Breast �� 55
Rosemary Oaks, Austin Cusick, and Shannon C. Trotter

v

,vi Contents

10 40-Year-Old Male with Anal Itching�� 61
Ian McArdle, Kassandra Riggs, Austin Cusick,
and Shannon C. Trotter
11 55-Year-Old Post-Menopausal Female with
Genital Itching and Pain During Intercourse�� 65
Kassandra Riggs, Erica Haught, Austin Cusick,
and Shannon C. Trotter
12 26-Year-Old Female with Itchy, Blisters on the
Bilateral Arms and Buttocks�� 71
Natasha Baah, Austin Cusick, and Shannon C. Trotter
13 38-Year-Old Female with Intensely Itchy,
Erythematous Scalp and Muscle Weakness�� 77
Ian McArdle, Pankaj Bansal, Austin Cusick, and Shannon C. Trotter
14 52-Year-Old Female with Itchy Skin After
Showering and Red Palms�� 85
Michael Goldenberg, Ashwin Kumar, Daniel Manzanillo,
Austin Cusick, and Shannon C. Trotter
15 31-Year-Old Female with Diffuse Itchy Skin and
Nail Changes�� 91
Abbey Cusick, Amandeep Goyal, Austin Cusick,
and Shannon C. Trotter
16 73-Year-Old Male with Diffuse, Itchy Skin�� 97
Ashwin Kumar, Daniel Manzanillo, Austin Cusick,
and Shannon C. Trotter
17 49-Year-Old Male with Itchy Skin and Abnormal
Liver Function Tests After Antibiotic Use�� 103
Harsh Patel, Ziyue Wang, Austin Cusick, and Shannon C. Trotter
18 65-Year-Old Male with Itchy, Dry Skin �� 109
Abbey Cusick, Amandeep Goyal, Austin Cusick,
and Shannon C. Trotter
19 56-Year-Old Female with Itchy, Dry Skin and Hair Loss�� 117
Erica Haught, Ian McArdle, Austin Cusick, and Shannon C. Trotter
20 59-Year-Old Female with Diffuse Itchy Skin on Dialysis �� 123
Michael Goldenberg, Ashwin Kumar, Lakmal Ekanayake,
Austin Cusick, and Shannon C. Trotter
21 72-Year-Old Male with Diffuse Itching�� 129
Ashwin Kumar, Lakmal Ekanayake, Austin Cusick,
and Shannon C. Trotter

,Contents vii

22 47-Year-Old Female with Diffuse Itching
Not Alleviated with Scratching �� 135
Michael Lawless, Harsh Patel, Austin Cusick,
and Shannon C. Trotter
23 64-Year-Old Male with Diffuse Itching After
Starting Amlodipine�� 141
Ziyue Wang, Michael Lawless, Austin Cusick,
and Shannon C. Trotter
24 27-Year-Old Pregnant Female with a Pruritic
Eruption on the Trunk and Extremities�� 149
Luke Bushrow, Austin Cusick, and Shannon C. Trotter
25 50-Year-Old Male with Diffuse Itching�� 155
Luke Bushrow, Austin Cusick, and Shannon C. Trotter
Index�� 161

,Chapter 1
72-Year-Old Male with Itchy,
Erythematous Papules on His Trunk

Amy Mehlman, Austin Cusick, and Shannon C. Trotter

A 72-year-old male presented with itchy, erythematous papules on his trunk, most
concentrated in the middle of his chest and back. The eruption had been present for
6 months and treated unsuccessfully with topical clotrimazole and over the counter
emollients. He reported using a hot tub on a daily basis and stated that the lesions
often look like a blister and they pop very easily.
On physical examination, there were multiple erythematous and pink papules,
some with hemorrhagic crust mostly concentrated on the chest and back. Several
were excoriated. A biopsy of one of the lesions was obtained and showed spongiotic
dermatitis with acantholysis.
Based on the clinical case description, what is the most likely diagnosis?
1. Psoriasis
2. Seborrheic dermatitis
3. Grover’s disease
4. Confluent and reticulated papillomatosis

Diagnosis

Grover’s disease.

A. Mehlman · A. Cusick
Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
S. C. Trotter (*)
Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
Dermatologists of Central States, Canal Winchester, OH, USA
e-mail:

© The Author(s), under exclusive license to Springer Nature 1
Switzerland AG 2021
S. C. Trotter, A. Cusick (eds.), Clinical Cases in Pruritus, Clinical Cases
in Dermatology, https://doi.org/10.1007/978-3-030-66274-5_1

, 2 A. Mehlman et al.

Discussion

Grover’s disease (GD), also known as transient and persistent acantholytic derma-
tosis, is a benign, pruritic skin condition first described by Ralph Grover in 1970, for
whom it is named [1]. GD presents as an intensely pruritic, erythematous rash
described as papular to papulovesicular in nature, with lesions commonly crusted
over or eroded [1, 2]. These lesions may also be described as papulosquamous [1].
The lesions most commonly appear on the trunk but are also located on proximal
extremities. The neck, face/scalp, palms, soles, axilla, and mucosal membranes are
affected but to a lesser degree. Duration of the rash caused by GD is typically self-
limited and clears within a few weeks; however, GD may also be chronic with a
waxing and waning presentation or a recalcitrant pattern for several years [1, 2].
While classically associated with severe pruritus, the pruritic association with GD
may vary from mild to severe. Treatment of GD not only targets the initial manifes-
tations and inflammation, but the treatment also is used to manage the itch co-
existing with the disease [2].
The incidence and prevalence of GD have yet to be firmly established, but some
sources report the incidence to be between 0.1–0.8% [1, 2]. GD has a predominance
towards males more commonly than females with a 2:1 ratio, and the mean age of
onset between the ages of 62–64 years [2]. However, there have been reported cases
of GD in young adolescents and older populations. GD is more commonly seen in
white patients but has also been reported in black, Hispanic, and Middle Eastern
patients to a lesser degree [2].
There are many suspected triggers and inciting medications that may lead to
GD. Proposed triggers include heat, diaphoresis, sunlight, ionizing radiation, and
prolonged bed rest. Other heat-related triggers include exercise, fever, hot tub bath-
ing, and unspecified excessive heat [3]. Several medical conditions can be impli-
cated in GD development such as end-stage renal disease, hemodialysis, solid organ
transplantation [4], atopic dermatitis, contact dermatitis, xerosis cutis, pyoderma
gangrenosum, bacterial infections, viral infections, tinea versicolor, scabies, and
malignancies [1, 2]. While heat and diaphoresis are suggested triggers, many cases
are paradoxically associated with cold, dry air [1, 2]. Some investigation has sup-
ported that GD was diagnosed at a rate four times higher during winter months than
in the summer, suggesting that xerotic skin and cold, dry air conditions may pro-
mote the disease [5]. Medications that are associated with GD include sulfadoxine-
pyrimethamine, ribavirin, anastrozole, interleukin-4, cetuximab, BRAF inhibitors
(vemurafenib, dabrafenib), and immune checkpoint inhibitors such as ipilimumab
[1]. If medication-induced, the inciting medication is typically continued, with the
addition of symptomatic management for pruritus [2]. Ultimately, all of the risk fac-
tors discussed culminate to the point of disrupting epidermal integrity. Over time,
the disruption of epidermal integrity predisposes the patient to develop GD [3].
Moreover, hypothesized occlusion of pores and epidermal ducts lead to direct epi-
dermal damage from molecular seepage into the epidermis. Rarely, autoantibodies
to desmoglein protein have been implicated [3]. Other associations are only linked
to GD by pure speculation.

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