A case of neurodermatitis circumscipta of scalp presenting as patchy alopecia.

Neurodermatitis or Lichen simplex chronicus (LSC) is chronic skin disease in which emotional factors have a key role in the initiation of disease. A sixty year old lady presented with itcy lesion of scalp with localised area of loss of hair. After proper history taking and investigations she was diagnosed as LSC of scalp. She was treated with intralesional steroids,oral doxepin and psychotherapy. Complete remission of symptoms with total regrowth of hair occured in 3 months. The key role of emotional factors in causation of LSC and a proper psychotherapy along with dermatological treatment is necessary for complete cure of this condition.

INTRODUCTION

Neurodermatitis circumscripta also commonly called as lichen simplex chronicus (LSC) is a chronic skin disease characterized by lichenified plaques, which occur as result of constant scratching or rubbing of skin. Itch sensation that provokes an intense desire to scratch or rub a localized accessible area of skin is secondary to a psychological stress. Common sites are nape of neck, ankles, anogenital region and scalp. Effective management of skin conditions involves correction of the associated emotional factors.

CASE REPORT

The present case report is about a 60-year-old female patient who presented to dermatology out-patient department with itchy scalp lesion of 2 years duration. She also had complaints of localized loss of hair in that area. There was no history of any local applications. There was no history of any drug intake. On examination, there was a localized area of alopecia of 4 cm × 4 cm size with underlying skin showing marked thickening to form a boggy swelling [Figure 1] on the right parietoccipital region. There were no other skin lesions or hair and nail changes. Systemic examination was within the normal limits. Provisional diagnosis of LSC of scalp and tinea capitis was made. Woods lamp examination was negative and potassium hydroxide mount did not reveal any fungal hyphae. Routine blood and urine investigations, blood sugar, liver, renal and thyroid functions were normal. On further interrogation patients bystanders gave a history that patient at times uses rock stones to rub scalp and may continue rubbing until it bleeds. Skin biopsy revealed hyper keratosis hypergranulosis acanthosis thickening of collagen in dermis suggesting LSC. Patient was given intralesional injection of triamcinolone acetonide 2.5 mg/ml weekly for 4 weeks along with doxepin hydrochloride 10 mg at night. Patient was referred to Psychiatry Department for counseling. There was marked reduction in itching in the 1st week and complete regrowth of hair at end of 4 weeks. Doxepin was stopped after 3 months [Figures 2 and 3]. Patient came for follow-up monthly thereafter for 6 months with no relapse [Figure 4].

Figure 1

Boggy swelling with loss of hair

Figure 2

Partial growth after 2 months

Figure 3

Total regrowth after 3 months

Figure 4

After 6 months no recurrence

DISCUSSION

Psychogenic factors play a key role in the initiation of pruritic sensation in LSC.[1] Itch scratch cycle is paroxysmal and patient scratches until it pains or bleeding occurs. This self-perpetuating mechanism is the main pathogenesis of LSC.[2] Skin lesions are that of a chronic eczema characterized by lichenified plaques. Most common sites are nape of neck, ankle, scalp and anogenital region.[3] Emotional tension causes lichen simplex and in turn patients with LSC in particular areas of the body (face, scalp, hands and genital area) are more prone to psychological distress due to the appearance of lesions. Although not life-threatening, it can produce an important psychosocial burden, sleep disturbance and sexual dysfunction.[4] Overall dermatology life quality index was lower in one study in patients with neurodermatitis than psoriasis.[5] Personality profiles of 60 patients with LSC were compared to a normative sample of the normal Spanish population, who were free of any kind of skin disease. Participants with LSC presented personality characteristics that differed from the control group. The most significant variables were as follows: greater tendency to pain-avoidance, greater dependency on other peoples’ desires and more conforming and dutiful compared to the control group.[6] Effective management of skin conditions involves simultaneous correction of psychological factors else recurrence is the rule.

Complications like secondary infection and occurrence of squamouscell carcinoma is also reported in studies.[7] Topical treatment modalities for LSC with varying success are potent topical steroids, intralesional steroids,[8] keratolytic agents such as salicylic acid, capsacin, tacrolimus pimecrolimus and cryotherapy. Systemic modalities of treatment include sedative antihistamines, tricyclic antidepressants and psychotherapy. Transcutaneous electric nerve stimulation has been reported to be effective in reducing itch.[9] Botulinum toxin[10] and topical doxepin cream are also reported useful.[11]