Dermatosis neglecta: a case report

INTRODUCTION

The term dermatosis neglecta was coined in 1995 by Poskitt et al.¹ This condition occurs as a result of inadequate cleansing of a localized part of the body due to various factors like psychiatric illnesses, neurological disorders, recent surgery or radiotherapy involving that part of the body. This leads to progressive accumulation of sebum, dirt, corneocytes and keratin material. It is characterized clinically by hyperpigmented and verrucous lesions over the affected area. Rubbing with alcohol soaked gauze or washing with soap and water removes the debris revealing the underlying normal skin.

CASE REPORT

A 50-year-old woman presented with a one month history of blackish raised lesions on anterior aspect of chest on the right side and right axillary region. She was a known case of carcinoma of right breast and had undergone mastectomy of right breast 7 months back along with chemotherapy. On examination multiple hyperpigmented, waxy and verrucous papules were seen on right side of chest over the site of mastectomy (Figure 1) and right axilla (Figure 2). Seborrheic dermatitis and Darier’s disease were kept as differential diagnosis. Seborrheic dermatitis was ruled out due to absence of similar lesions in other seborrheic areas. Darier’s disease was ruled out due to absence of other features of Darier’s disease. Upon further questioning she revealed that she had not washed the area with soap for fear of injury to the operated site. On suspicion we rubbed the lesion with spirit and cotton bud which resulted in removal of the lesion revealing the underlying normal skin (Figure 3). The patient was then advised to cleanse the operated area regularly with soap and water.

DISCUSSION

Dermatitis neglecta (DN) also known as unwashed dermatosis is a condition secondary to the accumulation of sebum, sweat, corneocytes and bacteria forming a hyperkeratotic plaque. Due to absence of inflammation, the terminology was changed in 1999 to dermatoses neglecta by Ruiz-Maldonado et al.² It is an underdiagnosed condition in which there is progressive accumulation of keratin, debris, dirt leading to characteristic skin lesions.³ It usually occurs in patients with poor hygiene due to inadequate cleansing of a part of the body. Inadequate cleansing may be due to various reasons such as pain (following surgery), paraesthesia, physical disability (due to hemiplegia or loss of limb), psychiatric illnesses, keloidal scars, site of pacemaker insertion.⁴ Dermatoses neglecta should be kept in mind in all cases that present with verrucous papules. Differential diagnosis includes dermatitis artefacta, verrucous naevi, acanthosis nigricans, Vagabond's disease, hyperkeratotic Malassezia dermatosis as well as confluent and reticulated papillomatosis of Gougerot and Carteaud, frictional asymptomatic darkening of the extensor surfaces, idiopathic deciduous skin, post-inflammatory hyperpigmentation.³ Terra Firma Forme Dermatosis (TFFD) is a condition with similar clinical presentation. Differences between these two conditions are given in (Table 1).⁵

In difficult to diagnose cases, biopsy of the lesion may be performed. Histopathology shows orthokeratosis, papillomatosis, acanthosis, and anastomosing rete ridges without lymphocytic infiltration.⁶ Other causes with similar presentation can be ruled out with biopsy. Although not many studies have been conducted about this condition, several cases have been reported from different parts of the world in recent times. Rasool Quadir SN reported a case of DN in a patient with multiple traumatic injuries.⁴ Moon J et al. described Dermatoses neglecta in a patient with rosacea who habitually applied excessive moisturiser and cleaned her face too softly. Consequently the lesions were glistening with whitish scales instead of the usual dirt like brown lesions.⁶ Saha A. reported three cases of dermatoses neglecta one on the chest of the patient with right breast mastectomy. The second patient was a 60-year-old lady with lesions on sternal area which developed as a result of not washing the area following open heart surgery and with pacemaker insertion. The third case was a 52-year-old female patient of pityriasis rubra pilaris with lesions on the face.⁷ Perez Rodrigues et al. reported a case of 18-year-old lady with dermatoses neglecta over face as a result of inadequate cleansing due to depression.⁸

Treatment of dermatosis neglecta includes counseling and encouraging the patient to maintain appropriate hygiene of the affected region.⁴ If the patient is unable to keep himself clean due to disability, the care taker has to make sure to cleanse the areas regularly. Daily light scrubbing of the affected area with soap and water or alcohol is effective in most cases. If lesions are resistant or hyperkeratotic, salicylic acid or glycolic acid containing cleansers can be used. Topical keratolytic agents like urea, lactic acid or salicylic acid can be used along with moisturisers.⁸

CONCLUSION

Dermatosis neglecta is frequently misdiagnosed mainly because of the lack of familiarity with the condition among the physicians. Dermatologists have to be aware of this entity and suspect it in appropriate case scenarios. This will avoid unnecessary investigations and provide great relief to the patients, his family members and the treating doctor.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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