Dermatitis neglecta

Sanjiv V Choudhary¹ , Shazia Bisati¹ , Sankha Koley²

¹ Department of Dermatology, Jawaharlal Nehru Medical College, Sawangi, India
² Department of Dermatology, B.S Medical College, Bankura, India

Correspondence Address:
Sanjiv V Choudhary
28, Modern Nagpur Society, Chhatrapati Nagar, Nagpur-15, Maharashtra
India

A 56-year-old male patient who was a case of trigeminal neuralgia referred from the ENT department, presented with asymptomatic dark brown verrucous plaque just above the left eyebrow since 3 months. Patient was asymptomatic 2 years back, then he gradually developed unilateral neuralgic pain involving left side of the forehead which became so severe that even the blow of the air was perceived as pain by him. Out of fear and pain he had not washed his face with water since 6 months. Clinical examination revealed dark brown, waxy, verrucous plaque just above the left eyebrow [Figure - 1]. No other body part was involved and there were no systemic symptoms.

Figure 1 :Dirty, waxy and verrucous plaque above left eyebrow

The area above the left eyebrow was cleaned with a spirit swab, revealing dirt and debris on the swab [Figure - 2] with completely normal skin underneath [Figure - 3].

Figure 2 :Alcohol swab test showing dirt and debris

Figure 3 :Completely normal underneath skin after alcohol swab test

The term dermatitis neglecta was first coined by Poskitt et al. in 1995. Dermatitis neglecta is an often misdiagnosed and under-diagnosed condition. In dermatitis neglecta, a progressive accumulation of sebum, sweat, keratin and other dirt and debris occurs resulting in a localized hyperpigmented patch or a verrucous plaque. Failure to adequately clean or scrub the skin, often in an area of hyperesthesia or prior trauma, can produce dermatitis neglecta. This has similarities to dermatitis artifacta, although in the latter condition the lesions are associated with acts of commission whereas in dermatitis neglecta the dermatitis is associated with acts of omission. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. Treatment includes counseling and encouraging the patient to maintain appropriate hygiene of the affected region in spite of his or her disability. Daily light scrubbing of the affected area with soap and water or alcohol is effective in most cases. For more resistant and verrucous lesions, application of a keratolytic agent in combination with an emollient may be required.

Early and prompt clinical recognition of this condition and its cause eliminates the need for aggressive diagnostic and therapeutic procedures.

Dermatitis neglecta should be kept in mind in the differential diagnosis of all hyperpigmented localized lesions, especially in a patient with some accompanying disability. The time of evolution is usually 2-4 months and the patients usually have an associated chronic disease characterized by pain or immobility. In our case patient was suffering from neuralgic pain and allodynia due to which patient was neglecting that area and was unable to maintain local hygiene. Alcohol swabbing can serve as a diagnostic and therapeutic tool in dermatitis neglecta. In our case also when the lesion was rubbed with alcohol-soaked gauze it leads to complete disappearance of the skin lesion with normal skin underneath. The result of treatment surprised our patient who was initially reluctant to admit that the condition is due to negligence.

There are several conditions described in the literature with similar clinical features. Terra firma forme dermatosis is recognized as dirty patches unaffected by soap and water cleansing but easily cleared with isopropyl alcohol. It is distinguished from dermatitis neglecta by the history of normal washing and lack of cornflake-like scale. Histopathologically, PAS-positive yeast can be present. Confluent and reticulated papillomatosis of Gougerot and Carteaud has a velvety appearance and is commonly associated with Pityrosporon orbiculare. It is distributed on the central trunk and is not related to cleansing. Confluent and reticulated papillomatosis has a negative alcohol swab test. Other conditions in the differential diagnosis include verrucous naevi, acanthosis nigricans, Vagabond′s disease, hyperkeratotic Malassezia dermatosis, frictional asymptomatic darkening of the extensor surfaces, idiopathic deciduous skin and postinflammatory hyperpigmentation.

Dermatitis neglecta is an underreported, asymptomatic, but aesthetically bothersome dermatosis. Dermatologists need to be aware of this condition that can be clinically diagnosed and effectively and inexpensively treated.