Dermatosis neglecta in schizophrenia: a rare case report.

Dermatosis neglecta is a chronic, dermatologic disorder results in ignored, neglected body parts due to chronic disability or painful conditions. There is scarcity of literature supporting the existence of dermatosis neglecta in the context of psychiatric illnesses. In this case report, we attempts to highlight, dermatosis neglecta in a homeless patient suffering from schizophrenia.

INTRODUCTION

Dermatosis neglecta is a chronic, progressive, dermatologic disorder results from the accumulation of sebum, keratin, dirt and other epidermal debris forming a hyper-pigmented, corn flake like scaly or plaque lesion.[1] It is a neglected, ignored skin condition. Dermatosis neglecta is described more in the context of painful and disabling conditions, which led to neglect of appropriate skin care.[1] Dermatosis neglecta frequently results from neglected skin areas due to improper cleaning or scrubbing.[2] Usually, the areas of skin affected are those with hyperesthesia or prior trauma.[2] The epidermal debris, keratin and dirt can be effectively cleaned by washing with soap and the scaly lesions are efficiently removed by swabbing with alcohol.[2]

CASE REPORT

The present case report is about a 35-year-old lady was brought by the non-governmental organization worker in a poor, disheveled state to the psychiatry emergency. The patient was found roaming in the road side in a disheveled condition, picking garbage, throwing stones at people. Detailed historical account of the patient was not available. She was having poor personal hygiene with unkempt hairs with patches of hair loss and crusting lesions on the skin of scalp, face and extremities. She had severe pallor in physical examination. On mental status examination, flow and volume of speech was increased, psychomotor activity was increased with marked uncooperativeness. Her affect was irritable. Third person auditory hallucination with occasional inappropriate smiling was found during the interview. Most of the times, she was talking irrelevantly, from which no conclusion can be drawn. Her judgment and insight were impaired.

Observation of ward behavior revealed — marked hallucinatory behavior, irrelevant speech, disorganized and disruptive behavior, poor self-care, disturbed sleep and socially disinhibited behavior. It was also reported that she used to scratch her genitals frequently. A gynecological opinion was taken and she was diagnosed as bacterial vaginitis for which she was prescribed antibiotics (ciprofloxacin 500 mg twice a day and metronidazole 400 mg thrice daily). Dermatology opinion was taken for her itchy, crusted, verrucous and scaly lesions of the body (located over chest, extremities and trunk) [Figures 1 and 2]. There were no signs of inflammation. There was no discharge of pus or induration at the site of lesion. There was no disruption in the epithelial integrity. She was diagnosed to have “Dermatosis neglecta.”

Figure 1

Verrucous lesion on the chest

Figure 2

Multiple, brownish pigmented, scaly lesions over the right arm, elbow and proximal forearm

Her routine blood and urine investigations revealed no abnormality other than anemia (hemoglobin — 8.0 g%). Peripheral blood smear is suggestive of hypochromic, microcytic picture. Red blood cell indices (mean corpuscular volume and mean corpuscular hemoglobin concentration) were below the normal range. Virological markers (human immunodeficiency virus, hepatitis B surface antigen) and venereal disease research laboratory were negative.

On the basis of serial mental status examination and observation of ward behavior, a psychiatric diagnosis of undifferentiated schizophrenia was made. She was started on antipsychotic risperidone 4 mg/day, which gradually escalated to 8 mg/day over a period of 4 weeks along with benzodiazepine lorazepam (4 mg/day) which was gradually withdrawn. The patient had shown improvement with the above medications in her psychiatric condition.

DISCUSSION

In our patient, we had no information about the onset, course, initial clinical manifestations, family history, premorbid level of functioning and personal details of the patient as the patient was a homeless female brought by a non-government voluntary organization. Our psychiatric diagnosis was based on cross-sectional clinical evaluation followed by serial mental status examination and observation of ward behavior in an in-patient setting. In this context, whether homelessness attributed to psychiatric illness or psychiatric illness attributed to homelessness is not known.

Disorganized behavior, poor self-care is seen in many psychiatric conditions. Due to poor self-care, the personal hygiene deteriorates and it leads to deposition of dirt, keratin, sebum and sweat over the skin which in turn forms crusts or scales over the skin. Growth of bacterial and fungal pathogens leads to dermatitis. In psychiatric conditions such as schizophrenia, affective disorders (depression, bipolar affective disorder), mental retardation, substance use disorders, catatonia etc.; where due to the underlying illness, the individual is unable to take care of general skin hygiene hence increasing the risk for development of cutaneous disorder like dermatitis neglecta.

There is scarcity of literature support, regarding the association of dermatitis neglecta in psychiatric disorders. Chronic disabling psychiatric conditions, where the individual is not able to take care of him/herself or there is lack of care provider to look after the patient with psychiatric illness, are highly likely to be associated with dermatitis neglecta.

An important differential diagnosis of dermatitis neglecta is dermatitis artefacta.[2] The conceptual difference between dermatitis neglecta and dermatitis artefacta are: the former results from the act of omission and the later results from the act of commission.[2] Other differential diagnoses of dermatitis neglecta are: Acanthosisnigricans, atopic dermatitis, icthyosis, idiopathic deciduous skin etc.[345]

In our case, the patient was suffering from schizophrenia. She was a homeless, untreated lady with poor psychosocial support. Due to her mental illness, she was not able to maintain her personal hygiene and skin care, which resulted in development of dermatitis neglecta. After dermatology opinion, the cutaneous debris and crusts were cleaned with soap water followed by alcohol swab cleaning.

Dermatosis neglecta is a dermatological condition first described by Poskitt et al. in 1995,[6] where 3 cases of pigmented hyperkeratotic lesions were described which were secondary to poor cleanliness and care. Subsequently this condition has been described in cases having poor cleanliness due to hyperesthesia, prior trauma or disability and other physical conditions. There is a need of alertness to identify this dermatological condition in patients of chronic or severe mental illnesses as this condition is easily treatable and reversible.

This is the first case report of description of dermatitis neglecta in schizophrenia. While evaluating such psychiatric conditions one should be aware of the dermatologic condition “Dermatitis neglecta” which can be simply managed with proper cleaning of the skin.