Dermatosis Neglecta: A Retrospective Study at a Tertiary Care Center in Southern India

Abstract

Background:

Dermatosis neglecta (DN) is an acquired skin condition that occurs due to unconscious neglect of self-cleaning in individuals with some underlying risk factor.

Aims and Objectives:

The purpose of this study was to summarize the demographic, clinical characteristics, and treatment outcomes of patients with DN in a tertiary care center.

Methods:

We evaluated the medical records of 28 patients with DN who were diagnosed and treated in our center between August 2020 and July 2022. The retrospective data related to demographic details, duration of lesions, morphology, distribution of lesions, associated symptoms, history of cleanliness, a risk factor for the development of the condition, treatment provided, and the details of follow-up were taken into account and analyzed.

Results:

Of the 28 patients, there were 19 males and nine females. The most common site in our study was the anterior trunk (n = 7) followed by the posterior trunk (n = 6). The most common site to develop DN was a recent surgical site. Soap and water cleansing resulted in the removal of lesions in the majority of the patients. Recurrence was observed in two patients.

Conclusion:

Our study indicates that the frequency of this condition is often underestimated and under-reported. To the best of our knowledge, this is the largest case series of DN in the medical literature.

Introduction

Dermatosis neglecta (DN) is an acquired skin condition, that occurs due to the unconscious omission of self-cleaning in individuals with certain physical or mental debilitation.[1] It is a relatively newly documented entity in the medical literature, with its first case documented in 1995 by Poskitt et al.[2] It is clinically characterized by localized, hyperpigmented, or yellowish-brown papules and polygonal plaques with cornflake-like scales.[3,4] Although DN is a common dermatological condition, it is often misdiagnosed and under-reported.[1] Only case reports and a few case series of DN are reported in medical literature for the sake of novelty and there is a paucity of systematic studies on the clinico-epidemiological data of these patients. Hence, we have undertaken this study and described the demography, clinical profile, and therapeutic outcomes of a series of 28 patients with DN at our institute seen over 2 years.

Methods

This was a retrospective descriptive study conducted based on the review of medical records of patients who were diagnosed with DN in a tertiary care center over 2 years (August 2020 to July 2022). We included all the patients with DN, who received care in the Dermatology department, and inpatient referrals from other clinical departments to the dermatology unit for expert opinion. The diagnosis of DN was based on the fulfillment of the following criteria: (i) clinical presentation of dirt-like hyperpigmented or yellowish papules and polygonal plaques with cornflake-like scales, (ii) history of localized and/or generalized cleanliness, and (iii) removal of lesions by washing with soap water (positive soap water test). Dermoscopy was performed in a few of the cases.

The retrospective data related to age, gender, duration of lesions, morphology, distribution of lesions, associated symptoms, history of cleanliness, risk factor for the development of the condition, treatment provided, and the details of follow-up were taken into account and analyzed. Of 32 cases of DN, four were excluded due to inadequate demographic data and clinical information. Statistical analysis of the retrieved data was performed using mean, proportions, and percentages. Approval from the SMVMCH Ethics Committee has been obtained.

Results

During the 2 years of study, a total of 28 cases of DN were encountered in our institution. There were 19 males and nine females (M:F = 2.1:1). The mean age of the patients was 37.3 ± 12.2 years. The DN lesions in the majority of the patients (23) were asymptomatic. Pruritus and foul odor were noticed in two patients. The mean duration of development of DN in 21 patients was 2.3 ± 1.4 months (range: 1 month-5.5 months). Seven patients were unaware of this condition, and DN was noticed as an incidental finding by the dermatologist. The expert opinion for DN lesions was sought by the Department of Plastic Surgery (four cases), surgical oncology (three cases), orthopedics (two cases), and psychiatry (two cases).

The anterior trunk (n = 7) was the most common site involved, followed by the posterior trunk (n = 6) [Figure 1]. Lesions were localized in all the patients, except one. The most common risk factor noticed in our study was the pain associated with recent surgery. Keloid was the most common dermatological condition associated with DN [Figure 2]. Dermoscopy was performed in five cases. Six patients were lost to follow-up. Two patients had a recurrence of DN lesions. In 20 cases, soap-cleansing and water-cleansing resulted in the removal of DN. Only in one case, topical keratolytic was needed. The characteristics of the 28 patients with DN encountered in our institute is summarized in Table 1.

Figure 1.

(a) Dirt-like hyperpigmented plaques over the anterior trunk in a patient with recurrent folliculitis; (b) Area after treatment with regular soap and water cleansing

Figure 2.

(a) Polygonal crusts over a keloidal scar due to lack of hygiene; (b) Dermatosis neglecta removed with soap and water cleansing

Table 1.

Summary of the epidemiological, clinical, and treatment outcomes of 28 DN patients included in the study

Epidemiological characteristics
Gender	Male	19: 67.9%
	Female	9: 32.1%
Age	Mean	37.3±12.2 years
	Range	4 months-68 years
Clinical characteristics
Symptom	Asymptomatic	92.8%
	Pruritus and foul odor	7.2%
Duration	Did not remember	25%
	Mean (n=21)	2.3±1.4 months
Distribution	Face and neck	21.4%
	Axilla	7.1%
	Anterior trunk	25%
	Posterior trunk (including shoulders)	21.4%
	Upper limbs	10.7%
	Genitals	10.7%
	Thighs	7.1%
	Lower limbs	7.1%
Extent	Localized	96.4%
	Generalized	3.6%
Risk factor	Surgical site	21.4%
	Keloid	14.3%
	Prolonged immobilisation	10.7%
	Hypertrophic scar	10.7%
	Plaster of Paris application	7.1%
	Recurrent folliculitis, Schizophrenia, Chronic depression, Cerebral palsy, Diaper use, Segmental leiomyoma, Postherpetic neuralgia, soft-tissue sarcoma	1 case each
	No obvious risk factor	2 cases: 7.1%
Treatment characteristics
Treatment provided	Scrubbing with soap and water	71.4%
	Removed with a saline-soaked moist gauze	14.3%
	Scrubbing with ethyl alcohol	10.7%
	Topical keratolytic	3.6%
Follow-up	No recurrence	71.4%
	Recurrence observed	7.1%
	Lost to follow-up	21.4%

Discussion

DN is a dermatological condition characterized by improper hygiene and inadequate scrubbing of the skin leading to progressive accumulation of sweat, sebum, dirt, keratinous debris, and bacteria.[1,5,6,7] It does not have a predilection for any gender, although our patients were predominantly men.[8] In our study, adults constituted 25 cases and only three were children. It generally takes 2-4 months for the development of DN as observed in this study. The lesions of DN are usually asymptomatic. As observed in two of our cases, previous reports of pruritus and malodor associated with DN have been reported in the literature.[9,10]

Proper elicitation of the patient’s skincare habits and risk factors for developing DN should be identified.[1] The inciting risk factors such as chronic disability, hyperesthesia, pain, prior surgery, trauma, old age, and sensitive skin can lead to DN.[1,4,11] In our study, a previous surgical site (21.4%) was the most common risk factor associated with the development of DN. Many of those patients mentioned that they avoided cleaning the surgical site even after the healing of the wound due to the fear of secondary infection. This points out the need for improvement in health education regarding proper surgical site care among patients.

Keloid was the inciting factor in 14.3% of the patients. Interestingly, reports of DN arising in keloid and/or its vicinity are scarce.[1] Two of our patients had underlying psychiatric morbidity (chronic depression and schizophrenia). DN is also reported to occur with other diseases with a psychiatric background such as frank psychosis, schizophrenia, obsessive-compulsive disorder, dementia, intellectual disability, mood disorders, catatonia, paranoia, and substance abuse disorder.[3,12,13,14]

It was interesting to observe that the anterior trunk, an easily accessible site while showering was the most common to be involved in our study. Also, six patients had DN over the face and neck despite the negative self-image experienced by the patients [Figure 3]. Genital DN was observed in a 68-year-old male with schizophrenia and in a 4-month-old child with continuous diaper use [Figure 4]. A child with cerebral palsy and fracture of the left tibia had generalized DN extending from the upper trunk to the lower extremities [Figure 5]. Similarly, generalized cases of DN mimicking psoriasis vulgaris and crusted scabies have been reported in the literature.[15,16]

Figure 3.

(a) Dirt-like waxy scales in a patient who recently underwent surgical excision of sebaceous cyst; (b) Follow-up photograph after treatment

Figure 4.

(a) Dark, dirt-like speckled scales over the penile shaft, in a schizophrenic patient; (b) After cleaning the area with a moist saline gauze

Figure 5.

(a), (c) Generalized DN in a cerebral palsy child; (b), (d) Improvement of DN lesions, after treatment with soap and water cleansing

In this study, only 35.7% (10 patients) volunteered themselves for dermatologist consultation for their DN lesions. The majority (39.3%) of the DN lesions were observed by other clinical specialty doctors and referred to the dermatology unit and 25% of DN lesions were incidentally observed by the dermatologists during their consultation for different skin conditions such as keloid and hypertrophic scar [Figures 6-9]. The asymptomatic nature was found to be the reason for poor health-seeking behavior in our patients. Many of our patients were reluctant initially to admit the lack of cleanliness.

Figure 6.

(a) DN in a patient with Plaster of Paris application; (b) After scrubbing with alcohol swab

Figure 9.

(a) DN over the flap reconstruction site in a patient with carcinoma of the buccal cavity. The patient had pain at the site and hence maintained poor hygiene; (b) The site after treatment with a saline-soaked moist gauze

Figure 7.

(a) Cobblestone pavement-like appearance of scales in a patient with sarcoma over neck region; (b) Partial improvement with soap and water cleansing

Figure 8.

(a) DN in a hypertrophic scar; (b) After improvement in skin hygiene

Terra-firma forme Dermatosis is a very close differential diagnosis of DN characterized by its predominance among the younger age group; maintenance of good hygiene; favoring sites such as the face, trunk, umbilicus, and ankle; removal with 70% isopropyl alcohol; and resistant to emollients and oil detergents.[1,17] The other common differential diagnosis is confluent and reticulated papillomatosis, pigmented pityriasis versicolor, hyperkeratotic head and neck Malassezia dermatosis, dirty neck of atopic, dermatitis artefacta, verrucous epidermal nevi, and several forms of ichthyosis.[1,5]

The diagnosis of DN is often clinical. Removal of lesions with soap water is often confirmatory, therapeutic, and helps in differentiating Terra-firma forme Dermatosis.[1,5] Dermoscopy is an ancillary tool that shows well-delimited cornflake-like brown waxy scales with the absent pigmentary network [Figure 10].[18] A high index of suspicion avoids unnecessary diagnostic procedures such as biopsy.[19]

Figure 10.

(a) Dermoscopy under polarized mode (DL4 dermoscopy: Dermlite LLC, San Juan Capistrano, CA, USA) of dermatosis neglecta showing dark-brown, polyhederal, cornflake-like scales (red circle), arranged in a “cobblestone pavement pattern”; (b) Honey colored crusted plaques (black arrow) in a “cobblestone pavement pattern”

DN has a good prognosis with an excellent response to treatment measures.[4] Recurrence can occur if the underlying predisposing factors are not addressed and there is a lack of adherence to hygiene measures.[20] In our study, two cases with underlying psychiatric morbidity (chronic depression and schizophrenia) had recurrence after 2 months of complete resolution of DN lesions. Recurrences of DN can be prevented by nonjudgmental counseling of patients who have risk factors to develop DN, encouraging the patient to maintain good hygiene and daily gentle scrubbing of the affected site with soap and water.[1] The scales in DN may harbor malassezia furfur due to the conducive environment for its growth.[10] In our study, we found a case of DN with coexistent pityriasis versicolor [Figure 11]. The potassium hydroxide scrapping from one of the DN lesions showed a Malassezia furfur organism. The lesion resolved with hypopigmentation in one of our patients.

Figure 11.

(a) DN in a patient with prolonged immobilization; (b) More evident pityriasis versicolor after treatment of DN lesions with saline-soaked moist gauze

Nonjudgmental counseling and proper health education to maintain good hygiene are vital in the management of DN.[1] The treatment of DN is often simple, very effective, and inexpensive.[21] For most cases, scrubbing with soap and water scrubbing is often sufficient. It can also be removed with saline-soaked moist gauze, ethyl or isopropyl alcohol swabs, methanol swabs, acetone, or mild cleanser [Figure 12]. Topical keratolytics such as urea, salicylic acid, lactic acid, glycolic acid, or retinoids can be administered in verrucous and resistant cases.[1] The limitations of this study include its retrospective nature and small sample size.

Figure 12.

Dirt-like material on an alcohol swab after removal of dermatosis neglecta in one of our patients

Conclusion

The prevalence of DN is often misdiagnosed and underestimated due to its asymptomatic and benign nature. The possibility of DN should always be considered in dirt-like dermatoses, especially with underlying risk factors to develop it. Our study indicates that DN is probably not as uncommon as previously thought to be. To the best of our knowledge, this is the largest case series of DN in the medical literature. We advocate more prospective studies with a larger case number in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.