Dermatosis Neglecta and Plica Polonica in Schizophrenia: Rarely Encountered or Rarely Discussed!

Sir,

Dermatosis neglecta is a condition that frequently results from chronic neglect toward skin hygiene leading to accumulation of sebum, dirt, and other epidermal debris giving rise to characteristic skin lesions.[1] The condition was first described by Poskitt et al. in 1995.[2] Plica polonica (neuropathica) is a similar condition of neglected hair hygiene leading to matting, crusting, and formation of a sticky-moist hair mass.[3] Sometimes the matting and crusting is so severe that it appears like “birds nest.”[4] Probably, female gender carries a higher risk, as females grow their hairs long, but having a febrile illness or curly hairs possesses added risk.[4]

Many times the terms - “dermatitis neglecta” and “dermatosis neglecta” are interchangeably used. It can mimic several dermatological conditions such as psoriasis, acanthosis nigricans, and dermatitis artefacta.[5] In psychiatric disorders such as schizophrenia, mood disorders, intellectual disability, and even dementia, where patients were neglectful to personal cleanliness, the risk of developing dermatosis neglecta, as well as plica polonica increases. Other than patients with psychiatric illness, many saints and individuals involved in rigorous spiritual practices neglecting their personal hygiene, may also have plica polonica and dermatitis neglecta.

A homeless adult male was brought to emergency psychiatry services by police personnel. He was wandering in a roadside in unhygienic, disheveled state, wearing dirty clothes with a foul odor coming from the body. He was found persistently muttering to self. No details of psychiatric and medical history were available. On general examination, there was a chronic nonhealing wound over his left ankle. He had long, thick crusted, moist matted hairs suggestive of plica polonica [Figure 1]. There were dark-pigmented, crusted lesions over the forehead, cheeks, and hand suggestive of dermatosis neglecta [Figure 1]. His psychomotor activity was increased. He was uncooperative, irritable, and talking irrelevantly, so a meaningful mental status examination was not possible. He was started with antipsychotic. As patient's general condition was poor with severe anemia and deranged electrolytes, he was referred for urgent management of medical conditions. Such cases are often seen with poor general and hygienic conditions in the streets, roadsides, and public places. Most of them are homeless, often untreated. They constitute an often ignored and neglected part of society, whose presence seldom counted. Their condition rarely catches the attention of researchers.

Figure 1

Long, thick crusted, moist matted hairs suggestive of plica polonica and dark-pigmented, crusted lesions over the forehead, cheeks, and hand suggestive of dermatosis neglecta

Plica polonica and dermatosis neglecta are results of neglected personal hygiene and unfortunately these conditions are also neglected in clinical research. Web search using the keywords “dermatosis neglecta” and “plica polonica” in PubMed database revealed only 23 and 14 articles, respectively, out of which most are case studies (single case study or case series), with only three case reports discussing the issue with psychiatric disorders, which shows that the entity is rarely discussed. Lack of help seeking behavior, presence of multiple co-morbidities and absence of proper consenting authority may be the major reasons for non-inclusion of such cases in clinical research. These conditions are clinically relevant and do not need rigorous pharmacological interventions. There is a need to just concentrate on personal hygiene by cleaning the skin and shaving or cutting of hairs.[4] These conditions are commonly prevalent in a number of homeless or chronically neglected patients in developing countries like India.

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Conflicts of interest

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