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An Unusually Severe Case of Dermatosis Neglecta

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Abstract 

Dermatosis neglecta is an asymptomatic skin condition, primarily caused due to chronic lack of hygiene. This disease presents as lesions on the skin surface, formed from the accumulation of sebum, dirt, and other epidermal debris. Characteristic features of this condition include the formation of hyperkeratotic plaques located in a specific region of the body. The risk factors predisposing to development of such lesions are: chronic disability, old age, sensitive skin, trauma, psychiatric condition or neurological deficit. The condition is difficult to diagnose since its lesions are almost indistinguishable from other skin abnormalities, for instance, hyperkeratotic syndromes or hyperchromic lesions.  

Here, we describe one such case of dermatosis neglecta which led to multiple differential diagnosis and presented as a diagnostic challenge.

Case presentation

The present case is about an 18 year old female suffering with dermatosis neglecta. The patient had a history of progressive brown plaque on her face. Previoushad not been successful in improving her symptoms.   

Owing to the seborrheic pemphigus and foliacues pemphigus, Darier’ disease was suspected. However, seborrheic dermatitis was confirmed as a result of biopsy with histopathological and immunofluorescence study. Patient also had a history of depression, social withdrawal, as well as non-compliance to the treatment and clinicians’ instructions. Facial cleansing carried out during the appointment led to the disappearance of the lesions, thereby confirming dermatosis neglecta. [1] 

Dermatosis neglecta or unwashed dermatosis was first described in 1995, as a condition secondary to the accumulation of sebum, sweat, corneocytes and bacteria resulting in the formation of a hyperkeratotic plaque. In the year 1999, this condition was renamed as dermatosis neglecta, because its lesions are devoid of inflammation. 

Dermatosis neglecta is an asymptomatic condition and therefore, often underdiagnosed. This condition affects all age groups and both males and females. Old age is a risk factor for the development of such lesions, owing to physical disability and a tendency to neglect self-care among the geriatric population. Patients with psychiatric disorders are also at high risk of developing dermatosis neglecta, due to habitual neglect of personal hygiene in a majority of such patients. 

The lesions present as hyperkeratotic plaques with cornflake-like scales which may have formed over 2 to 4 months. Usually, the lesions disappear with thorough washing of the affected areas. Diagnosis is almost entirely dependent on clinical examination – lesions can be identified by removing the crusts with isopropyl alcohol. A biopsy is usually not necessary and orthokeratotic hyperkeratosis, papillomatosis and mild acanthosis can be observed without an inflammatory infiltrate. 

Differential diagnoses include: terra firma-forme dermatosis, confluent reticulated papillomatosis of Gourgeot and Carteaud, acanthosis nigricans, verrucous nevi, vagabonds disease, and genetic disorders such as Dariers disease and X-linked ichthyosis. Terra firma-forme dermatosis is clinically comparable to dermatosis neglecta; its differentiating features are history of good hygiene and response to cleaning. While dermatitis artefacta presents as self-inflicted injury or injury worsened by the patient, unlike dermatosis neglecta which is an act of omission of cleaning by the patient, intentionally or otherwise.  

An important distinguishing feature of dermatitis neglecta, from other closely mimicking lesions, for instance terra firma-forme dermatosis, is that its lesions disappear on adequate cleansing. Treatment measures for dermatosis neglecta involve reinforcing hygiene measures and using keratolytic agents such as urea, retinoic acid, glycolic acid, lactic acid. 

Conclusion

Dermatosis neglecta is a skin condition which may present as a diagnostic challenge. A detailed history and clinical examination are keys to confirmatory diagnosis of such lesions, rather than invasive investigative techniques such as biopsy. In cases where dermatosis neglecta is suspected, a detailed medical and family history along with an elaborate interview with the patient may be useful in disclosing an underlying psychological condition.  

These lesions can be successfully treated with simple measures, such as appropriate cleansing, adequate hygiene, and topical application of keratolytic agents. The key to an efficient treatment lies in an early diagnosis of these lesions, since numerous differential diagnoses may coincide with the clinical presentation, for example hyperkeratotic syndromes. Moreover, an early diagnosis of dermatosis neglecta facilitates the avoidance aggressive diagnostic and therapeutic procedures.

References

  1. I. Pérez-Rodríguez, F. Muñoz-Garza and J. Ocampo - Candiani, "An Unusually Severe Case of Dermatosis Neglecta: A Diagnostic Challenge", Case Reports in Dermatology, vol. 6, no. 2, pp. 194-199, 2014.
  2. S. Kar, J. Singh and P. Singh, "Dermatosis neglecta and plica polonica in schizophrenia: Rarely encountered or rarely discussed!", International Journal of Trichology, vol. 8, no. 2, p. 100, 2016.
  3. A. Saha, J. Seth, A. Bindal, A. Samanta, S. Gorai and A. Sharma, "Dermatosis neglecta: An increasingly recognized entity with review of literature", Indian Journal of Dermatology, vol. 61, no. 4, p. 450, 2016.
  4. J. Moon, H. Park, H. Yoon and S. Cho, "A Case of Dermatosis Neglecta Caused by an Inappropriate Habit of Applying a Moisturizer", Annals of Dermatology, vol. 29, no. 5, p. 657, 2017.
  5. N. Patra, M. Panda, S. Samant and S. Arora, "Dermatitis neglecta as a complication after cataract surgery", Indian Journal of Ophthalmology, vol. 64, no. 3, p. 231, 2016.
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