Two Pediatric Cases of Dermatitis Neglecta - A Neglected Entity Needs Awareness

Respected Sir,

Dermatitis neglecta, the “unwashed dermatosis” results from the accumulation of dirt, sebum, sweat, and keratin debris[1] over an area that has not been scrubbed properly while cleaning leading to incomplete exfoliation and formation of hyperpigmented, verrucous plaques with “cornflake-like” scale.[2] The entity was first described by Poskitt et al. in 1995.[3] It is an underreported, asymptomatic, but aesthetically bothersome dermatosis. Proper awareness among clinicians avoids unnecessary interventions. Herein, we report two interesting pediatric cases of dermatitis neglecta.

A 14-year-old male patient presented to the outpatient department (OPD) with an asymptomatic, hyperpigmented discoloration over the left axilla of about 4 months duration [Figure 1] He had no other complaints. The patient had undergone a wide local excision and reconstructive surgery for hidradenitis suppurativa on both axillae prior to the appearance of the lesion, leading to extensive scarring along the suture lines of operated fields. On repeated asking, the patient confessed that he had avoided washing or scrubbing the area due to fear of interfering with the healing process. Clinical examination revealed a hyperpigmented verrucous plaque with a greasy appearance and irregular margin overlying hypertrophic scars along the suture lines and around, in the left axilla near the medial aspect of the left upper arm. He had been operated on both axillae [Figure 2]. From the history and clinical examination, the case was suspected to be of dermatitis neglecta. On close inspection, hyperpigmented materials were found to be accumulated between the hypertrophic scars along the suture lines on both sides. Other differentials considered were terra firma-forme dermatosis, acanthosis nigricans, and verrucous epidermal naevus. The area was then vigorously rubbed with cotton soaked in soap water and a large amount of dirt and debris came away on the cotton swab revealing normal skin underneath [Figure 3]. A good percentage of the lesion was cleared [Figure 4]. We did not have any dermoscopic facility to examine. The biopsy was found to be inconclusive. On psychiatric referral, no psychological comorbidities could be elicited. The patient was counseled regarding personal hygiene and advised daily scrubbing with soap water. He was asked to return at 2 weeks but was lost to follow-up.

Figure 1.

Hyperpigmented, verrucous plaque along the suture lines and around, in the left axilla near the medial aspect of the left upper arm

Figure 2.

Hypertrophic scar along the suture line of the operated field in other axillae

Figure 3.

Cotton swab with dirt

Figure 4.

Partial clearance of the hyperpigmented, verrucous plaque following scrubbing with soap and water-soaked cotton swab

A 12-year-old female patient with fever and rash for a few weeks duration was referred from the pediatric department for an opinion about a hyperpigmented, scaly plaque over her right cheek [Figure 5]. The child was diagnosed to be a case of systemic lupus erythematosus. The plaque was developing slowly for the last 3 months. Unusual location, morphology, and apathy of the patient to touch the area prompted us to rub with cotton soaked in soap and water. A good amount of dirt came out. We instructed daily scrubbing with soap and water. After 7 days, all the dirt was removed. The underlying skin revealed a healed lesion of discoid lupus erythematosus with some erythematous rash at the surrounding area [Figure 6]. Interrogation revealed the girl initially had this cheek lesion 8 months back and was treated for this lesion by quacks with off and on topical steroid creams. She developed the hypopigmented scar, which her parents wanted to get rid of. A traditional healer advised them not to touch the area otherwise it may spread all over the face. Interrogation revealed the girl used to avoid peer interaction and play outside to avoid social criticism.

Figure 5.

Hyperpigmented, scaly plaque over the right cheek

Figure 6.

Healed lesion of discoid lupus erythematosus after the removal of dirt

Dermatitis neglecta is often a misdiagnosed as well as underdiagnosed condition. It is a direct consequence of poor hygiene, which may be due to psychiatric illness, neurological deficit, surgical scar, hyperesthesia, or other pre-existing dermatological conditions such as eczema or benign nevus.[4] Often, neglect is associated with a fear of aggravating the underlying condition. History of such neglect may not always be forthcoming.

The diagnosis is easily established by clearing away the lesion by scrubbing with soap water or alcohol swab. Patients should be counseled regarding maintenance of proper hygiene and advised to scrub the area daily with soap and water. Keratolytics and emollients may be reserved for resistant cases.

Terra firma-forme dermatosis is an important differential that needs to be considered. However, unlike dermatitis neglecta, patients maintain good hygiene and the lesions cannot be removed by soap water scrubbing and are only removed by rubbing with alcohol swabs. Also, the lesions are dirty brown plaques that lack the “cornflake-like” scale.

Awareness regarding this relatively common condition is still quite low among many clinicians.[5] A high index of suspicion avoids unnecessary diagnostic and therapeutic interventions.[6] Results are instantaneous and extremely gratifying to both patient and physician. We report this condition as it is under-reported and a strong inclination is required to pick up these cases. Also, to the best of our knowledge, dermatitis neglecta with these unique presentations in pediatric patients has not been reported. Increasing awareness will reduce the rate of misdiagnosis of this condition, which can be inexpensively and effectively treated.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.