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Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 241-242

Terra firma-forme dermatosis following episode of irritant contact dermatitis

Department of Dermatology, Institute of Child Health, Kolkata, West Bengal, India

Date of Submission09-Jan-2020
Date of Decision30-Jan-2020
Date of Acceptance14-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Abhijit Saha
Rahul Apartment, Flat Number: 201 and 202, 20 Dutta Para Lane, Opposite to Durgabari, Doltala, Uttarpara - 712 232, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_6_20

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How to cite this article:
Saha A, Malakar R, Baherjee R, Dhar S. Terra firma-forme dermatosis following episode of irritant contact dermatitis. Indian J Paediatr Dermatol 2020;21:241-2

How to cite this URL:
Saha A, Malakar R, Baherjee R, Dhar S. Terra firma-forme dermatosis following episode of irritant contact dermatitis. Indian J Paediatr Dermatol [serial online] 2020 [cited 2021 Jun 24];21:241-2. Available from: https://www.ijpd.in/text.asp?2020/21/3/241/288503


Terra firma-forme dermatosis (TFFD) is a benign, idiopathic, acquired condition characterized by gray-brown patches or plaques, which can easily be removed by vigorous rubbing with 70% isopropyl alcohol-soaked gauze piece. The condition was first described by Duncan et al. in 1987, hence also called as Duncan's dirty dermatosis.[1] The phrase “terra firma” literally means dry land or solid land. Resolution of the lesion following the application of 70% isopropyl alcohol is both diagnostic and therapeutic.[2],[3] Suspicion of this entity is necessary in appropriate cases to avoid unnecessary laboratory testing, biopsy, and medications. Lack of familiarity with this benign condition among dermatologists probably leads to underreporting. An 8-year-old boy presented to the pediatric dermatology outpatient department (OPD) with “dirty” looking rash on the lower part of the front of neck extending to the upper part of the chest, composed of multiple pigmented keratotic papules of 2 months' duration [Figure 1]. Lesion is asymptomatic but unsightly, which forced parents to bring the child to OPD out of apprehension. The boy had suffered from irritant contact dermatitis of the neck fold 3 months back due to insect dermatitis, followed by inadvertent use of some raw antiseptic lotion over that area for few days. Parents were instructed by a pediatrician not to use scrubber or antiseptic lotion, which may further aggravate the condition. Only gentle washing with water and soap/cleanser was allowed. The boy was advised mild topical steroid and moisturizer for the affected area for 2 weeks only. His washing habit is normal otherwise with at least one bath per day. Mother has tried several times to remove the plaque with soap and water. However, all were in vain. Clinical differentials considered were TFFD, dermatitis neglecta, and dirty neck of atopic and epidermal nevi.[4],[5] Biopsy was not attempted. Partial clearance of the lesion was achieved with forceful swabbing of the area with alcohol-soaked pad [Figure 2] and [Figure 3]. Mother was instructed to scrub the area with 70% isopropyl alcohol weekly and come back for follow-up after 3 weeks. Complete clearance was noted at 3-week follow-up visit. There was no recurrence at 3-month follow-up period. TTFD can affect any age group and both sexes. Some reports favor higher incidence in pediatric age group. Like our case, neck, ankle, face, and trunk are the common sites of involvement. Distribution varies from localized, generalized, unilateral, bilateral, or symmetrical. Despite classical presentation, lesions may be verrucous or papillomatous. Lesion in our patient was clustered, pigmented keratotic papules. Dermatitis neglecta (DN) is the closest differential and considered to be separate entity. DN occurs in individuals with poor or neglected personal hygiene. Lack of frictional cleansing in DN leads to the accumulation of corneocytes, sebum, sweat, and bacteria and clinically presents as hyperpigmented patch or hyperkeratotic plaque. Lesions can effectively be removed with normal washing with soap and water. Effective clearance can also be achieved with isopropyl alcohol. Pathogenesis of TFFD is still an enigma. Abnormal and delayed keratinocyte maturation is the most probable answer. Ultimate outcome is the retention of keratinocytes and melanin in the epidermis along with dirt and sebum.[6],[7] It can be said that TTFD is a retention hyperkeratosis rather than proliferative hyperkeratosis. Histopathology is a good reflector of underlying proposed pathogenesis, in terms of lamellar hyperkeratosis with whorls of compact orthokeratosis, acanthosis, papillomatosis, and increased melanin both in basal and hyperkeratotic layers. Absence of parakeratosis cannot be explained by the proposed mechanism. DN is histopathologically similar with TTFD except whorled hyperkeratosis. TTFD can be differentiated from DN on the basis of appropriate hygiene, absence of corn flake-like scales, and lack of response to soap water swabbing. In our case, although the child has an adequate hygiene habit, he was instructed by the physician to avoid scrubbing of his diseased skin. This may have provoked incomplete removal of remnant of soap/cleanser and accumulation of the same. Repeated application of topicals adds to the condition. The true pathogenesis of this enigmatic disorder still eludes us; this case of ours may trigger searches in newer avenues, such as presence of preceding dermatosis, topical steroid use, or incomplete cleaning, which may act as trigger or contributory factor to the development of the condition. Further studies are needed to establish this fact.
Figure 1: “Dirty” looking rash on the lower part of the front of neck extending to the upper part of chest, composed of multiple pigmented keratotic papules

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Figure 2: Partial clearance of the lesion following alcohol swabbing

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Figure 3: Dirty alcohol swab

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol 1987;123:567-9.  Back to cited text no. 1
Akkash L, Badran D, Al-Omari AQ. Terra firma forme dermatosis. Case series and review of the literature. J Dtsch Dermatol Ges 2009;7:102-7.  Back to cited text no. 2
Guarneri C, Guarneri F, Cannavò SP. Terra firma-forme dermatosis. Int J Dermatol 2008;47:482-4.  Back to cited text no. 3
Akkash L, Badran D, Al-Omari AQ. Terra firma forme dermatosis. Case series and review of the literature. J Dtsch Dermatol Ges 2009;7:102-7.  Back to cited text no. 4
Berk DR. Terra firma-forme dermatosis: A retrospective review of 31 patients. Pediatr Dermatol 2012;29:297-300.  Back to cited text no. 5
Berk DR, Bruckner AL. Terra firma-forme dermatosis in a 4-month-old girl. Pediatr Dermatol 2011;28:79-81.  Back to cited text no. 6
Thomas RS, Collins J, Young RJ, Bohlke A. Atypical presentations of terra firma-forme dermatosis. Pediatr Dermatol 2015;32:e50-3.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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