Dermatosis Neglecta: An Increasingly Recognized Entity with Review of Literature.

Sir,

Dermatosis neglecta (DN) represents a failure to adequately clean an area of hyperesthesia, trauma, or immobility leading to the development of hyperpigmented, verrucous plaques with adherent, cornflake-like scales.[123] Localized area of scaling and hyperpigmentation is a frequent finding in our discipline but it often poses a diagnostic and therapeutic challenge, and DN should be considered as a differential diagnosis in this context. DN is characterized by fastidious avoidance of scrubbing either because of some physical debility, neurological deficit, or some psychiatric illness. This is an extension of the case series what we have reported a short time ago.[4] In this occasion, we again came across few interesting cases with diverse background.

A 35-year-old male patient presented with multiple hyperpigmented patches and hyperkeratotic plaques over his left temporal region near the hairline for the last 3 months Vigorous scrubbing with soap water removed most of the dirt exposing underlying normal skin [Figure 1a and b]. On interrogation, we found that the patient had undergone ear surgery few months back probably due to tympanic membrane perforation. Initial pain and discomfort in the immediate postoperative period prevented him from regular cleansing of the affected region. He continued the same even after 1 month in fear of damaging the area. The patient was counseled regarding adequate cleansing of the operated area.

Figure 1

(a) Hyperkeratotic plaques over his left temporal region near the hairline (b) Removal of dirt with vigorous rubbing with soap water

Our second patient, a 55-year-old male with chronic plaque psoriasis visited outpatient department for gradual thickening and blackening of an area over his left knee for the last 6 months [Figure 2a and b]. He had consulted many places for the complete cure of his psoriasis. However, the efforts were found to be unsatisfactory as disease followed its waxing waning course. This time, he had hardly any concern of his preexisting lesion, rather he was much worried about the newly developed hyperpigmented plaque. On repeated interrogation, he admitted that he had a blunt trauma over his left knee few months back for which he stopped washing the affected region in fear of having psoriasis at a new site. The crusts were cleared completely on wiping the area with soap water followed by spirit swab [Figure 2c and d].

Figure 2

(a) Hyperpigmented plaque over left knee. (b) Hyperpigmented plaque over left knee (close-up). (c) Removal of dirt on rubbing the area with spirit swab. (d) Underlying normal skin revealed after cleansing

The third case was a young female presenting with generalized hyperkeratotic plaques all over the body with predominant involvement of face and acral parts [Figures 3a–c]. Initially considered as a disorder of keratinization but after thorough history, it was revealed that patient had a history of postpartum convulsion 2 months back for which she was treated with anticonvulsants. Moreover, as per verbal information and documentation provided, she had an episode of morbilliform drug rash to anticonvulsant for which she was treated conservatively. However, even after subsidence of the skin lesion, patient avoided bathing for more than 1 month as a part of socioreligious belief as she was in postpartum period and also to keep her skin free from any external insult. On suspicion, we rubbed the skin with soap water and spirit swab which resulted in partial removal of the plaques. Then, the patient was advised to apply keratolytics with adequate cleansing of the whole body with soap water and was asked to report after 1 week. On the very next visit, there was near complete removal of the plaques revealing underlying normal skin [Figure 4a and b].

Figure 3

(a) Hyperkeratotic plaques over the face. (b) Hyperkeratotic plaques over the chest. (c) Hyperkeratotic plaques over acral parts

Figure 4

(a) Complete removal of the plaques revealing underlying normal skin following regular cleansing and application of keratolytics. (b) Plaques over the upper limb cleared to a great extent after adequate cleansing

DN is often a misdiagnosed entity due to its similarity with several other conditions such as verrucous nevi, acanthosis nigricans, X-linked ichthyosis, hyperkeratotic pityriasis versicolor, and postinflammatory hyperpigmentation.[4] [Table 1] shows some of the recently reported cases where DN posed a diagnostic challenge because of its varied masquerading presentations and diverse background. Histopathological features are nonspecific. Only mention worthy point is a lack of inflammation and for which the nomenclature of the entity has been changed from dermatitis neglecta to DN.[1] As we mentioned in our previous article, terra firma-forme dermatoses a close mimicker of DN can be differentiated from DN by history of good personal hygiene, lack of cornflake-like scale, and unresponsiveness to soap water cleansing in the former. Dermatitis artefacta is a factitious disorder where patient self-inflict injury to evacuate inner sense of isolation or distress.[11]

Table 1

Some recently reported cases of dermatosis neglecta

Patient should be properly counseled to maintain good personal hygiene and keratolytics, and emollients should be used judiciously where necessary.

As mentioned in our previous article, this underrated entity is not very rare as thought earlier. Over a short span of time, we were able to identify three cases, so it can be inferred that this is an underestimate of the true prevalence of this entity as patients are asymptomatic and prefer to accept it.

Most of the previously reported cases were described in the context of painful and disabling conditions, which led to neglect of appropriate skin care, but now there is an increasing incidence of DN developing in a setting of psychiatric background or frank psychosis or schizophrenia[9] or even it may be a result of intentional neglect for some secondary gain.[6] Our present article reinforces our observation once again. Only proper awareness among treating physicians and increased consciousness among patients can reduce the rate of misdiagnosis, and the only simplest thing that can prevent invasive and expensive workup is thorough and proper history taking and a simple alcohol swab test. Efforts should also be made to address the underlying cause which in turn will be helpful for clinicians to boost the confidence of the patient regarding this harmless entity, and also at times, diagnosis of DN may unclothe some severe underlying disease such as malignancy.[12]

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.