Case Letter
Terra firma-forme dermatosis: an underdiagnosed condition
Bruna Anjos Badaró
, Lucia Martins Diniz, Paulo Sergio Emerich Nogueira
Corresponding author
Service of Dermatology, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitória, ES, Brazil
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This condition caused great social impact to the patient, given that she suffered from discrimination at school. She had used ketoconazole cream as prescribed by a physician of the Basic Health Unit; however, there was no clinical response. The patient noticed that the lesions became discreetly clearer after intense rubbing with gauze, but without improvement after washing with soap and water.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The dermatological examination indicated that the patient had hyperkeratotic brownish plaques with a dotted pattern, affecting the neck, back, abdomen, and, in a less evident manner, the lower limbs (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). After suspecting the presence of terra firma-forme, the lesions were rubbed with gauze embedded in 70% alcohol and the plaques were removed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">“Terra firma-forme” is a Latin expression, which means “solid earth”, also known as Duncan's dirty dermatosis. It is a benign and idiopathic skin disorder that was described in 1987.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> Its prevalence and incidence are unknown, because it is an underdiagnosed disorder.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The cases described in the literature have indicated greater involvement during childhood and adolescence.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathogenesis is uncertain; however, it is attributed to disturbance in the maturation of keratinocytes, leading to the compaction of these cells, associated with melanin, sebum, and microorganisms in the epidermis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> this fact explains the hyperkeratosis and hyperpigmentation clinically observed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This dermatosis is characterized by slightly elevated, brownish or blackened, hyperkeratotic, and asymptomatic plaques and papules. The lesions are typically located in the neck, face, and trunk, bilaterally or unilaterally. It affects patients with adequate hygiene habits, and the lesions are not removed by washing with soap and water.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">When the presence of the condition is suspected, dermatoscopy helps by detecting brownish polygonal plates arranged in a mosaic pattern.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> The diagnosis is confirmed by removing the affected area by firmly and persistently rubbing the skin with cotton soaked in 70% isopropyl alcohol.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a> This procedure possibly determines protein denaturation, interfering in the cell metabolism and diluting lipoprotein membranes,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> thus avoiding blood tests and skin biopsies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Histological evaluation is unnecessary; however, if performed, it can indicate acanthosis, papillomatosis, and lamellar hyperkeratosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Differential diagnoses are made with hyperpigmented lesions, including confluent and reticulated papillomatosis of Gougerot and Carteaud, which has some similar characteristics and is considered a superficial variant of that dermatosis. It is possible to differentiate them by removing the lesions with alcohol in terra firma-forme dermatosis, in addition to considering other clinical findings, such as for example, acanthosis nigricans, which is a skin disorder usually associated with metabolic disorders and dermatitis neglecta, easily washed with soap and water,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> among others.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment consists of the application of 70% isopropyl alcohol; however, the lesions may recur.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a> The skin should be washed with soap and water after using alcohol, taking into account the possible symptoms of intoxication as drowsiness, lethargy, respiratory depression, mucosal irritation, and others, especially in children. Absorption through the intact skin surface is low; however, it may increase after prolonged exposure.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> There is a report of the use of 5% salicylic acid once a day with a good response after two weeks.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The patients and families should be advised to clean the skin at home,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> in addition to the application of emollients for preventing xerosis caused by recurrent use of alcohol.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is important to recognize this dermatosis in order to avoid incompatible diagnostic and therapeutic procedures, as well as to reassure adolescents and family members, thus reducing social impact on patients’ lives.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Bruna Anjos Badaró: Conception and planning of the study; elaboration and writing of the manuscript; obtaining, analysis, and interpretation of the data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Lucia Martins Diniz: Approval of the final version of the manuscript; conception and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Paulo Sergio Emerich Nogueira: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-28" "fechaAceptado" => "2019-07-17" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Badaró BA, Diniz LM, Nogueira PSE. Terra firma-forme dermatosis: an underdiagnosed condition. An Bras Dermatol. 2020;95:397–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Universitário Cassiano Antônio Moraes, Vitória, ES, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 717 "Ancho" => 855 "Tamanyo" => 72893 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic brownish plaques with a dotted pattern affecting the abdomen.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 744 "Ancho" => 855 "Tamanyo" => 62490 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic brownish plaques with a dotted pattern affecting the back.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 602 "Ancho" => 855 "Tamanyo" => 53874 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Area without lesions after rubbing the skin with gauze embedded in 70% alcohol.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bilaterally symmetrical terra firma-forme dermatosis: a diagnostic conundrum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. 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Available from: <a target="_blank" href="https://pubchem.ncbi.nlm.nih.gov/compound/3776">https://pubchem.ncbi.nlm.nih.gov/compound/3776</a> [cited 16.02.19]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000003/v4_202007210853/S0365059620300866/v4_202007210853/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000003/v4_202007210853/S0365059620300866/v4_202007210853/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300866?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 22 | 11 | 33 |
| 2024 October | 112 | 69 | 181 |
| 2024 September | 170 | 82 | 252 |
| 2024 August | 214 | 115 | 329 |
| 2024 July | 196 | 114 | 310 |
| 2024 June | 168 | 83 | 251 |
| 2024 May | 105 | 72 | 177 |
| 2024 April | 123 | 87 | 210 |
| 2024 March | 133 | 62 | 195 |
| 2024 February | 168 | 83 | 251 |
| 2024 January | 123 | 57 | 180 |
| 2023 December | 123 | 61 | 184 |
| 2023 November | 163 | 81 | 244 |
| 2023 October | 161 | 94 | 255 |
| 2023 September | 161 | 70 | 231 |
| 2023 August | 170 | 45 | 215 |
| 2023 July | 185 | 51 | 236 |
| 2023 June | 205 | 53 | 258 |
| 2023 May | 148 | 29 | 177 |
| 2023 April | 136 | 31 | 167 |
| 2023 March | 148 | 56 | 204 |
| 2023 February | 119 | 42 | 161 |
| 2023 January | 90 | 33 | 123 |
| 2022 December | 93 | 34 | 127 |
| 2022 November | 115 | 63 | 178 |
| 2022 October | 160 | 105 | 265 |
| 2022 September | 94 | 64 | 158 |
| 2022 August | 99 | 67 | 166 |
| 2022 July | 79 | 63 | 142 |
| 2022 June | 82 | 56 | 138 |
| 2022 May | 70 | 55 | 125 |
| 2022 April | 70 | 56 | 126 |
| 2022 March | 76 | 71 | 147 |
| 2022 February | 97 | 35 | 132 |
| 2022 January | 109 | 76 | 185 |
| 2021 December | 63 | 58 | 121 |
| 2021 November | 67 | 62 | 129 |
| 2021 October | 107 | 88 | 195 |
| 2021 September | 98 | 55 | 153 |
| 2021 August | 93 | 63 | 156 |
| 2021 July | 71 | 54 | 125 |
| 2021 June | 62 | 52 | 114 |
| 2021 May | 78 | 72 | 150 |
| 2021 April | 186 | 328 | 514 |
| 2021 March | 116 | 72 | 188 |
| 2021 February | 38 | 34 | 72 |
| 2021 January | 58 | 18 | 76 |
| 2020 December | 43 | 17 | 60 |
| 2020 November | 53 | 16 | 69 |
| 2020 October | 48 | 15 | 63 |
| 2020 September | 66 | 15 | 81 |
| 2020 August | 83 | 8 | 91 |
| 2020 July | 265 | 11 | 276 |
| 2020 June | 32 | 17 | 49 |
| 2020 May | 16 | 9 | 25 |
| 2020 April | 0 | 6 | 6 |
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