Indian Journal of Dermatopathology and Diagnostic Dermatology

ORIGINAL ARTICLES
Year
: 2022  |  Volume : 9  |  Issue : 2  |  Page : 59--63

Dermatosis neglecta in inpatients of a tertiary care center: A case series


Sruthi Kareddy, Spoorthy Babu, Mamatha Pappala 
 Department of Dermatology, Venereology and Leprosy, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

Correspondence Address:
Spoorthy Babu
Department of Dermatology, Venereology and Leprosy, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru 560066, Karnataka
India

Abstract

Background: Dermatosis neglecta (DN) is an underdiagnosed localized pigmentary disorder, characterized by asymptomatic hyperpigmented patches and plaques with adherent scales in an inadequately cleansed area. It is a diagnostic challenge leading to unnecessary interventions and burden to patients. Dermoscopy is a noninvasive handy diagnostic tool, though its utility in the diagnosis of DN is unexplored. Objective: To describe the various clinical and dermoscopic patterns in patients with DN. Materials and Methods: An observational study in 10 admitted patients of a tertiary hospital with DN was done, who consulted in department of dermatology in view of hyperpigmented lesions. After a thorough history and clinical examination, dermoscopy was done over the lesions. Results: In 10 patients, DN was confirmed with a resolution of part of lesion on the application of water-soaked gauze. On dermoscopy, dark-brown polygonal, cornflake-like scales are seen arranged in a mosaic pattern with intervening normal skin, sometimes over an erythematous background. On further probing, most patients gave the history of unintentional neglect of the affected part related to their primary illness. Limitations: Small sample size. Conclusions: DN is an underreported localized hyperpigmented disorder, mimicking other dermatoses. It should always be kept in mind in patients with morbidities that lead to the inability to maintain hygiene in the relevant areas, which may not be the classically described sites of DN. Dermoscopy helps to differentiate it from other hyperpigmented lesions, especially in its milder forms, avoiding the act of wiping the lesions especially in areas associated with hyperesthesia and helps in reinforcing the diagnosis. However, the criteria to diagnose DN based on dermoscopy is not definite.



How to cite this article:
Kareddy S, Babu S, Pappala M. Dermatosis neglecta in inpatients of a tertiary care center: A case series.Indian J Dermatopathol Diagn Dermatol 2022;9:59-63


How to cite this URL:
Kareddy S, Babu S, Pappala M. Dermatosis neglecta in inpatients of a tertiary care center: A case series. Indian J Dermatopathol Diagn Dermatol [serial online] 2022 [cited 2022 Nov 26 ];9:59-63
Available from: https://www.ijdpdd.com/text.asp?2022/9/2/59/359771


Full Text



 Introduction



Dermatosis neglecta (DN) is a rarely reported condition arising due to inadequate frictional cleansing, forming an adherent crust of dirt.[1] It mainly involves the trunk and flexures, presenting as hyperpigmented patches or plaques, associated with or without pruritus. These lesions resolve on cleansing with soap water.[2],[3] It mimics other hyperpigmented disorders, which makes it often to be misdiagnosed.[2] In its milder forms, dermoscope helps in diagnosing and distinguishing it from other disorders and avoids the act of wiping lesions in the clinic.[3]

There is a paucity of literature on this dermatosis, though being a common dermatological entity in hard-to-reach areas.

In this study, we described the clinical and dermoscopic features of DN in inpatients of our institute.

 Materials and Methods



An observational study was conducted in 10 inpatients of our tertiary hospital who were referred to our department between the period from September to December 2020, for hyperpigmented lesions. After obtaining informed consent, detailed history and demographic details of patients were collected. The diagnosis of DN was based on the clinical presentation of asymptomatic hyperpigmented patches/plaques, with a history of poor skin hygiene. It was confirmed with a saline wipe test after clinical suspicion. Dermoscopy was performed using a 10× polarized handheld dermoscope (DermLite DL4, 3Gen Inc.) attached to a mobile camera, before saline swabbing. Analysis of clinical and dermoscopic findings are presented as absolute numbers (percentage).

 Results



Ten cases were identified, out of which six (60%) were males and four (40%) females. Age ranged from 11 years to 60 years (mean 33.7 years). The most common lesion location was the arm and sides of neck in three (30%) patient’s each, followed by back in two (20%) cases. Less-commonly involved areas included the eyelid and chest in one (10%) patient each. Lesions were hyperpigmented dark to light brown plaques and patches. The mean duration of lesions as per the patient’s history was 3.2 weeks (range 1–5 weeks). Comorbid conditions associated were atopic dermatitis, diabetes mellitus in two patients each. The probable reason for neglect was pain/apprehension postsurgery/radiation in four patients, hyperesthesia in one case of systemic sclerosis, immobility in four patients, and physical barrier in the form of a cast in one. In postprocedural cases (surgery/radiation), DN was confined to affected areas only. In debilitated patients, it was seen in hard-to-reach areas or was extensive in some. All lesions were asymptomatic and readily cleared with gentle rubbing with saline swabs. No recurrences were seen in the patients who returned to the clinic for new concerns or follow-up of other conditions. The dermoscopic patterns observed included polygonal brown scales arranged in mosaic pattern [Figure 1]C, and plate-like light-brown scales [[Figure 2]B], with intervening normal skin. Two patients showed cornflake-like brown scales [[Figure 3]B] arranged haphazardly on dermoscopy. One patient had large scales, imparting a bluish hue, with background erythema. One patient also showed few regularly coiled hair which was due to the applied cast and its friction. All clinical and dermoscopic characteristics of patients are summarized in [Table 1].{Figure 1} {Figure 2} {Figure 3} {Table 1}

 Discussion



DN, also referred to as unwashed dermatosis, was first recognized and named by Poskitt et al. in 1995.[4] It is characterized by formation of an adherent compact crust of dirt due to inadequate frictional cleansing of an area of hyperesthesia, immobility, trauma, scar, secondary to psychiatric illness, or neurologic deficit.[2],[5],[6] There is an accumulation of sebum, sweat, keratinocytes, and bacteria in those areas. It affects all age groups, with no sex predilection, and is usually underdiagnosed.[7]

DN presents with asymptomatic hyperkeratotic, hyperpigmented patches, or verrucous plaques adhered with flakes and scales, most commonly involving the flexures and trunk.[7],[8] In our study, less commonly reported sites like eye and forearm were also involved depending on the site of intervention. Thus, it can occur at any site.

Dermoscopy of DN shows polygonal plate-like brown structures distributed irregularly as the most common feature, as seen by Cinotti et al. and Sasaya et al.[9],[10] It is due to the underlying histological background of basketweave hyperorthokeratosis, acanthosis, epidermal atrophy, and diminution of rete pegs with the absence of inflammation.[3],[6],[8] Few cases showed brown globular structures with everted edges, simulating cornflake-like scales over the peripheries, with background erythema, which was also observed by Errichetti and Stinco.[3] However, we did observe cases showing polygonal brown structures arranged in a mosaic-like pattern, similar to that seen in Terra firme-forme dermatosis (TFFD). This overlap was also observed by Kaliyadan et al.,[11] who attributed this appearance to their histological similarities. Large scales impart a bluish hue, identified by Kaliyadan et al.[11]

On vigorous cleansing with soap and water or alcohol-soaked gauze, complete resolution of lesions occurs. Patients should be counseled and encouraged about the maintenance of hygiene of the affected region. Treatment predominantly consists of light scrubbing the area with soap and water, with the use of keratolytic agents like urea, retinoic acid and, emollient in resistant cases.[2],[7],[12]

TFFD is a close differential diagnosis, which according to Martin et al. and Wollina et al. was synonymous with DN.[13],[14] Few authors differentiated the two entities based on the presence of adequate personal hygiene, lack of cornflake-like scales, negative saline swab test, and clearance with isopropyl alcohol (70%).[2] TFFD is said to be due to a delay in the maturation of corneocytes leading to melanin retention and compaction of scales. It usually presents with brown-grey, velvety pigmented plaques over the face, neck, and trunk.[2],[15] Dermoscopy of TFFD shows large, diffuse polygonal plate-like brown scales in mosaic pattern interrupted at fissures due to its characteristic histology of prominent papillomatosis, acanthosis, and compact hyperkeratosis.[3],[16] Additional patterns of linear and curvilinear structures with perifollicular hyperpigmentation are also reported.[11],[17]

The dermoscopic patterns of DN and TFFD are overlapping with blurred margins of differentiation clinically in its subtle forms[8],[18]

Confluent and reticulated papillomatosis, related to Pityrosporum orbiculare, is a benign acquired keratinization disorder which clinically presents with dry greyish blue papules with minimal scaling, confluent at the center and a reticulate pattern peripherally.[2] Dermoscopy of vconfluent and reticulated papillomatosis shows ridges and brown-colored fissures arranged in a crocodile skin-like pattern, with whitish structures over the ridges. Histopathological relates to pigmented epidermis and dermal papillomatosis.[16]

Dermatitis artefacta is a psychocutaneous disorder where-in the patient himself inflicts lesions, to satisfy an unconscious psychological need.[2]

Acanthosis nigricans, a cutaneous marker of insulin resistance, presents as velvety hyperpigmented plaques with increased skin markings over the intertriginous areas. Dermoscopy reveals linear crista cutis and sulcus cutis with focal black or brown dots and globules, and exophytic papillary structures in chronic lesions. It is due to elevated epidermis and papillomatosis, whereas sulcus is due to basketweave stratum corneum in downward epidermis.[19]

Hyperpigmented variant of pityriasis versicolor is a superficial fungal infection caused by Malassezia genus, which presents as multiple scaly macules coalescing to form large lesions, over the upper trunk and arms. Dermoscopic feature includes altered folliculocenteric pigmentary network with a contrast halo ring, associated with scaling.[20]

Other differential diagnosis include verrucous nevi, frictional melanosis, atopic dirty neck, postinflammatory hyperpigmentation, and various ichythosis.[2],[18]

 Conclusion



DN is an underdiagnosed and aesthetically problematic condition. While diagnosing any hyperpigmented localized lesions, in patients with some disability/pain, DN should be considered. Early clinical recognition avoids unnecessary diagnostic or therapeutic interventions. Histopathogical examination is not justified for the confirmation of the diagnosis in such benign conditions. Diagnosis is usually straightforward in DN and the saline wipe test is confirmatory. However, many at-time vigorous rubbing cannot be done due to pain/recent surgery at the affected area. Moreover, patients are often not convinced by a simple saline swab test. Dermoscopy can be handy in such cases to help to rule out other localized hyperpigmented lesions. DN shares few similarities clinically, histologically, and dermoscopically with many disorders, thus requiring further studies with a larger sample size to reach a definite criterion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Han YJ, Kim SY, Choi HY, Myung KB, Choi YW A case of dermatitis neglecta. Ann Dermatol 2008;20:257-9.
2Saha A, Seth J, Sharma A, Biswas D Dermatitis neglecta: A dirty dermatosis: Report of three cases. Indian J Dermatol 2015;60:185-7.
3Errichetti E, Stinco G Dermoscopy in terra firma-forme dermatosis and dermatosis neglecta. Int J Dermatol 2017;56:1481-3.
4Poskitt L, Wayte J, Wojnarowska F, Wilkinson JD “Dermatitis neglecta”: Unwashed dermatosis. Br J Dermatol 1995;132:827-9.
5Sanchez A, Duran C, de la Luz-Orozco M, Saez M, Maldonado RR Dermatosis neglecta: A challenge diagnosis. Dermatol Pediatr Lat 2005;3:45-7.
6Richter LL, Miller RM, Hillman JD, Chiu MW Bilateral thick crusts on the legs. Int J Dermatol 2013;52:133-5.
7Pérez-Rodríguez IM, Muñoz-Garza FZ, Ocampo-Candiani J An unusually severe case of dermatosis neglecta: A diagnostic challenge. Case Rep Dermatol 2014;6:194-9.
8Saha A, Seth J, Bindal A, Samanta AB, Gorai S, Sharma A Dermatosis neglecta: An increasingly recognized entity with review of literature. Indian J Dermatol 2016;61:450-2.
9Cinotti E, Perrot JL, Labeille B, Cambazard F Dermatitis neglecta after airbag deployment. J Eur Acad Dermatol Venereol 2016;30:707-8.
10Sasaya EM, Ghislandi C, Trevisan F, Ribeiro TB, Mulinari-Brenner F, Gaiewski CB Dermatosis neglecta. An Bras Dermatol 2015;90:59-61.
11Kaliyadan F, Feroze K, Kuruvilla J Dermoscopy of dermatitis neglecta in the periocular area in skin of color. Indian Dermatol Online J 2020;11:678-9.
12Chattopadhyay S, Ghosh S, Paul SS, Mukherjee A Dermatitis neglecta affecting nose: A case report. Indian J Otolaryngol Head Neck Surg 2019;71:1672-3.
13Martín-Gorgojo A, Alonso-Usero V, Gavrilova M, Jordá-Cuevas E Dermatosis neglecta or terra firma-forme dermatosis. Actas Dermosifiliogr 2012;103:932-4.
14Wollina U Unsusual manifestation of terra firme-forme dermatosis: Upper eyelid and orbital rim. Our Dermatol Online 2018;9:285-6.
15Erkek E, Sahin S, Çetin ED, Sezer E Terra firma-forme dermatosis. Indian J Dermatol Venereol Leprol 2012;78:358-60.
16Ankad BS, Dombale V, Sujana L Dermoscopic patterns in confluent and reticulated papillomatosis: A case report. Our Dermatol Online 2016;7:323-6.
17Abdel-Razek MM, Fathy H Terra firma-forme dermatosis: Case series and dermoscopic features. Dermatol Online J2015;21:13030/qt4rq5x48c.
18Sechi A, Patrizi A, Savoia F, Leuzzi M, Guglielmo A, Neri I Terra firma-forme dermatosis: A systematic review. Int J Dermatol 2021;60:933-43.
19Sonthalia S, Gupta A, Jha AK, Sarkar R Hyperpigmented disorders (disorders of pigmentation). In: Lallas A, Errichetti E, Ioannides D, editors. Dermoscopy in general dermatology. London: CRC Press; 2019. pp. 257-69.
20Kaur I, Jakhar D, Singal A Dermoscopy in the evaluation of pityriasis versicolor: A cross-sectional study. Indian Dermatol Online J 2019;10:682-5.