A striking case of dermatosis neglecta

Dear Editors,

Dermatosis neglecta results from the accumulation of sebum, sweat, keratin, corneocytes and bacteria in a localised area of skin, forming a compact and adherent crust of dirt. Although only a few cases have been reported in the literature, recognition of this condition is important in order to avoid aggressive, unnecessary diagnostic and therapeutic procedures 1. We report a case in which a patient developed striking lesions as a result of lymphoedema and neglect of personal hygiene.

A 45‐year‐old Caucasian woman was admitted to the dermatology ward with extensive areas of thickening and ulceration on the legs, which had developed over the past 6 months. She was morbidly obese and had a longstanding history of lymphoedema and self‐neglect. Physical examination showed thick, yellow/brown, hyperkeratotic plaques circumferentially distributed on the lower legs and ulcers above the ankles, associated with an offensive green exudate (Figure 1A and B). Swabs of the exudate grew Pseudomonas aeruginosa. Laboratory investigations revealed a C‐reactive protein of 165 mg/l (reference range, >10). Computed tomography scans of the thorax, abdomen and pelvis ruled out an underlying malignancy. Her legs were treated with topical keratolytics, including 20% salicylic acid paste under occlusion and a cream containing 10% urea and 5% lactic acid (Calmurid; Galderma, Watford, UK). Oral acitretin was initiated at a dose of 10 mg daily to reduce the hyperkeratosis. In addition, her legs were soaked in potassium permanganate solution. Oral metronidazole (400 mg three times daily) for the infection was given for 7 days. Gabapentin at a dose of 200 mg three times daily was administered for analgesia. She improved dramatically with desquamation of the hyperkeratotic plaques and reepithelialisation of the denuded areas (Figure 2A and B).

Figure 1.

(A and B) Thick yellow/brown hyperkeratotic plaques on lower legs with ulcers above ankles.

Figure 2.

(A and B) Dramatic improvement with nearly complete resolution of hyperkeratosis and reepithelialisation of eroded/ulcerated areas.

Dermatosis neglecta was first described by Poskitt et al. in 1995 2. It arises from inadequate frictional cleansing. The accumulation of sebum, sweat, keratin and other dirt results in the development of hyperpigmented, verrucous plaques with adherent cornflake‐like scales 3. Although most cases have been described in patients with painful and disabling conditions, there is an increasing awareness that dermatosis neglecta can develop in the context of a psychiatric illness. Patient denial of a lack of cleanliness is not uncommon 4. The histopathological features include a paucity of inflammation but are otherwise non‐specific 5. In milder cases of dermatosis neglecta, exfoliation with isopropyl alcohol could be sufficient to loosen the scale. However, in severe cases, topical keratolytics are necessary. This is the first report where hyperkeratosis was so severe that the addition of an oral retinoid was required. Every effort should be made to diagnose and treat any underlying psychological or psychiatric illness. Our patient was assessed by the psychiatric liaison team but was deemed not to have a psychiatric illness.

Dermatosis neglecta is an asymptomatic but cosmetically debilitating condition. Dermatologists need to be aware of this condition that can be clinically diagnosed and effectively and inexpensively treated. Our case is unique by virtue of the striking appearance of the patient's legs at presentation, the need for an oral retinoid and the dramatic improvement of the lesions with treatment.

Bhoyrul, B. , Goodfield, M. J .D. , Laws, P. M. (2017), A striking case of dermatosis neglecta. International Wound Journal. doi: 10.1111/iwj.12819