Dermatitis neglecta -- a dirty dermatosis: report of three cases.

Dermatitis neglecta is a condition that results from inadequate frictional cleansing leading to accumulation of corneocytes, sebum and sweat ultimately resulting in hyper-pigmented patch or verrucous plaque. Recognizing this condition avoids unnecessary, aggressive diagnostic and therapeutic procedures. Here we report three cases of dermatitis neglecta in whom the dermatitis developed as a result of intentional neglect of personal hygiene.

What was known?

Dermatitis neglecta is a rare disorder and is often misdiagnosed or under diagnosed.

Introduction

Dermatitis neglecta (DN) results from the accumulation of sebum, sweat, corneocytes, and bacteria in a localized area of skin, forming a compact and adherent crust of dirt. As it is often misdiagnosed or under diagnosed, very few cases had been reported in the literature till date. We report three such cases we came across in our OPD in a short span of few months.

Case Reports

Case 1

A 56-year-old female patient presented with discoloration over the right side of the chest region extending till the upper part of the arm for last 3-4 months. She had no other complain whether local or systemic. She had undergone right breast mastectomy 1 year back and had developed lymphoedema of the upper-right limb post-radiotherapy. Dermatological examination revealed greasy and, hyperpigmented patches [Figure 1]. On application of soap water, the lesions were partially cleared with removal of some dirt and debris over the swab, exposing near normal skin [Figure 2]. We did a biopsy from the remaining lesion and histopathology report was found to be nonspecific. We instructed the patients to scrub the lesions with soap water regularly and asked to come back for follow up. In the next visit, after 14 days, the lesions were completely cleared. She admitted that hyperesthesia over the region prevented her to wash the area regularly. The patient was advised to maintain hygiene.

Figure 1

Greasy and, hyperpigmented patches over upper-right limb

Figure 2

Exposing near normal skin after soap water cleansing

Case 2

A 60-year-old female patient presented with discoloration over upper chest since last 3-4 months. She complained of mild itching over that area. On examination, there were hyperpigmented macules and patches over the sternal area [Figure 3]. She underwent an open heart surgery for pacemaker installation 8 month back. On repeated interrogation, the patient admitted of not cleaning the area near the site of surgical incision in fear of damaging it. On wiping with the soap water-soaked cotton piece, a good amount of greasy scales and crusts were removed from the lesion. On further scrubbing with spirit, rest of the dirt was removed revealing the underlying normal skin [Figure 4]. Patient was counseled regarding her personal hygiene and was prescribed emollient to use for two weeks.

Figure 3

Hyper pigmented macules and patches over the sternal area

Figure 4

Underlying normal skin was revealed after scrubbing with soap water and spirit

Case 3

A 52-year-old female with classical adult type pityriasis rubra pilaris presented with progressive blackening and thickening of her facial skin since last 3 months. On examination, along with classical lesions of follicular hyperkeratotic papules in a typical distribution of pityriasis rubra pilaris, patient had hyperpigmented plaques mainly over the forehead, nose, periorbital, and perioral areas [Figure 5]. Initial soap water cleansing was followed by scrubbing with spirit; the areas were cleared to a great extent [Figure 6]. The lady admitted that she used to avoid scrubbing or soap water bath for last 3 months in fear of aggravation of her pre-existing skin disease.

Figure 5

Hyperpigmented plaques over the forehead, nose, periorbital, and perioral areas

Figure 6

Areas were cleared to great extent following scrubbing

Discussion

Dermatitis neglecta, also known as unwashed dermatosis, was first introduced by Poskitt et al., in 1995.[1] Etiology of this entity is yet to be fully explored. Inadequate cleansing and improper hygiene in an area of immobility, pain, hyperesthesia, prior trauma, and surgery leading to inadequate exfoliation of skin are supposed to be the inciting factors.[23] The ultimate outcome is accumulation of sebum, sweat, keratin, and other dirt in the form of localized hyper pigmented patch or a verrucous plaque with adherent, corn flake-like scales.[24] It is worth mentioning that terra firma forme dermatosis; close mimicker of DN is primarily due to delay in maturation of corneocytes and melanin retention.[567] In DN, denial from patient's side regarding lack of cleanliness is not uncommon. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. Patients should be counseled and encouraged that the maintenance of appropriate hygiene of the disabled affected region is beneficial rather than detrimental. Daily light scrubbing of the affected area with soap and water or alcohol is sufficient in most cases. Keratolytic agents and emollient are reserved for resistant cases. Early and prompt clinical recognition of this condition and its underlying cause lead to the avoidance of invasive diagnostic and therapeutic interventions.

DN should be kept in mind in the differential diagnosis of all hyperpigmented localized lesions, especially in those with a background of disability. In our first case, patient was suffering from allodynia of the affected area which prompted her to neglect local hygiene of the same. In the second case, the patient was scared of damaging the pacemaker so did not clean the surrounding area. In the last case, patient avoided scrubbing bath in fear of aggravation of her skin disease (pityriasis rubra pilaris). Alcohol swabbing serves as a diagnostic and therapeutic tool in dermatitis neglecta. Swabbing with soap and water also produces more or less similar result; evident in all of our three cases. Terra firma forme dermatosis is the closest differential and points favoring its diagnosis are the presence of adequate hygiene, lack of cornflake-like scales, and unresponsiveness of the dirty patch to soap water swabbing. Dermatitis Artefacta is a factitious disorder where lesions are produced or aggravated by patient himself with a background of psychiatric disturbance[8]. Confluent and reticulated papillomatosis of Gougerot and Carteaud often presents with dry grayish brown papules with minimal scaling that becomes confluent at the centre and extend peripherally in a reticulate pattern, most commonly in the intermammary region and is not related to cleansing.[9] It is commonly associated with Pityrosporum orbiculare and responds to oral Minocycline. Other conditions in the differential diagnosis include verrucous naevi, pityriasis versicolor,[10] acanthosis nigricans, postinflammatory hyperpigmentation, frictional hyperkeratosis, dirty neck of atopics, and several forms of ichthyosis. We believe that this is an underestimate of the true prevalence of this condition because the patients are mostly asymptomatic and fail to suspect the pathological nature of this apparently harmless entity.

Conclusion

As this disease can be easily treated by simple scrubbing with soap water or alcohol, proper awareness among clinicians will reduce the rate of misdiagnosis. At the same time an effort should be made to ascertain underlying cause, if any.

What is new?

This supposed to be rare entity is not that much rare as per our observation, faulty data are probably due to lack of consciousness and casual approach from physicians and patients as well.