Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Fluocinonide gel 0.05% should be applied twice a day. Never apply to the face, the axillae, or the genital areas. Desoximetasone may be used in place of fluocinonide. High potency (class I) topical steroids, such as Temovate or Diprolene, are limited to 2 weeks' use. They can cause atrophy if used longer and, therefore, should be avoided.
Hydroxyzine 10-30 mg can be used every 6 hours as needed for itching. As a substitute, Benadryl 25-50 mg may be used every 6 hours as needed. Both may cause drowsiness.
Retinoid-like Agents
Class Summary
These agents decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and they may reduce the potential for malignant degeneration. They also affect keratinocyte differentiation.
Isotretinoin (Amnesteem, Claravis, Myorisan, Sotret)
Isotretinoin is a synthetic 13-cis isomer of the naturally occurring tretinoin (trans- retinoic acid). Both agents are structurally related to vitamin A.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Prednisone
Prednisone is an immunosuppressant used for the treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Antineoplastics, Antimetabolite
Class Summary
These agents regulate cell growth and differentiation.
Methotrexate (Trexall, Rheumatrex)
Methotrexate is an antimetabolite that inhibits DNA synthesis and cell reproduction in malignant cells. It has an unknown mechanism of action in the treatment of inflammatory reactions; it may affect immune function. Methotrexate ameliorates symptoms of inflammation (eg, pain, swelling, stiffness).
Vitamins
Class Summary
Vitamins are are used to meet necessary dietary requirements and are used in metabolic pathways, as well as DNA and protein synthesis.
Vitamin A (Aquasol A, A-Natural-25, A-25)
Vitamin A is a cofactor in many biochemical processes. For refractory disease, vitamin A may be administered at 50,000 U 3 times a day for 2 weeks then daily for up to 12 weeks.
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A 54-year-old man with a pruritic eruption on the trunk. Notice the slight lichenification and significant erythema from rubbing that is localized to the central part of the torso. Also note the red-brown papules in the abdominal region.
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Close-up view of the abdominal area of a patient with a pruritic eruption on the trunk. Multiple, small, discrete, red-brown papules characteristic of Grover disease are present.
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Histopathology of Darier-type Grover disease. A focus of acantholytic dyskeratosis is present in the epidermis with slight epithelial hyperplasia and hyperkeratosis, a sign of rubbing as a consequence of the pruritic nature of the disease (hematoxylin and eosin, original magnification X40).
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Higher magnification reveals the acantholytic dyskeratosis to better advantage. Note the corps ronds and grains (hematoxylin and eosin, original magnification X400).
