Case Number : Case 4079 - 08 September 2022 Posted By: Saleem Taibjee

Subtle acantholysis with no dyskeratosis, somewhat lichenified - goes with history of pruritis; thinking Hailey-Hailey disease.

Agree with the above comment. Grover's is a differential.

My impression at a glance is of a PV, but it's an odd site and other clinical findings don't fit well. 

Itching..Blisters..Goes PV.. For DIF..

I have shown the initial level above. As you have all well-spotted, there is very subtle intra-epidermal clefting suggesting an acantholytic disorder.

The main point is to request further levels when the clinician is indicating a blistering disorder and the initial levels show only subtle features. The additional levels are shown below, and in contrast show a more dramatic acantholytic blistering process.

There is also dyskeratosis including corps ronds, suggesting an acantholytic dyskeratosis disorder. The clinical was suspecting Hailey-Hailey disease which seems to fit. There was no separate biopsy sent for immunofluorescence, but ideally this should be sent in such cases to rule out an immunobullous disorder. However, the genuine dyskeratosis would seem to make pemphigus unlikely here.

BW, Saleem

"..However, the genuine dyskeratosis would seem to make pemphigus unlikely here". Yes! totally agree!