BMH Medical Journal

Dermatosis Neglecta is a skin condition developing due to lack of proper cleansing of the skin. This is seen as hyper keratotic plaques with corn-flake like scales. Several case reports are there for this condition; we are presenting a very rare case of Dermatosis neglecta which presented as tumorous masses on the head of an elderly lady.

Introduction

Dermatosis Neglecta, otherwise known as Dermatitis Neglecta is a condition characterised by hyperpigmented hyperkeratotic plaques on the skin caused by wilful or subconscious neglect of proper cleansing.[1,2] The term was coined by Poskett et al in 1995 [1]. We present a case of Dermatosis Neglecta that resembled a tumour in an elderly lady. Such a case has not been reported earlier to the best of our knowledge.

Case report

An elderly, active, fully coherent lady, with no comorbidities, presented with two slowly enlarging asymptomatic swellings on her scalp. The lesions started 4 years ago after an attack of varicella and very gradually increased in size. She had no associated symptoms hence did not seek medical help. She would wash and dry her hair daily, taking care to avoid disturbing the affected area. Three weeks prior to attending the outpatient clinic she developed pruritus over one of the swellings, severe enough to interfere with her sleep.

On examination, she was afebrile. Her blood pressure was 120/70 mm Hg. Two moderately firm, non-tender swellings were observed on the scalp, one on the frontal area and the other over the vertex of 6x4 cms and 5x4 cms in size respectively (Figure 1). The surface was crusted and crumbling with embedded hairs and corn-flake like scales. A provisional diagnosis of Dermatosis Neglecta was made but considering the patient's age and tumourous appearance, and the presence of a dermoid cyst on the left forehead, an FNAC was attempted to exclude a tumour below the crust. This led to bleeding from the swelling and on compression to stop the bleeding, the swelling collapsed negating the possibility of an underlying solid tumour. Supported by the history that she was avoiding proper cleansing of the affected area, the diagnosis of Dermatosis Neglecta was confirmed.

Figure 1: Two tumorous masses on the vertex and frontal area

She was admitted and routine examinations like CBC, HB, RFT, LFT and blood sugar were within normal limits. As a first step, we attempted to remove the crusts with soaks of 2% soda bicarbonate solution. After 2 days, we were able to remove the swellings en masse leaving an ulcerated floor (Figure 2). She was treated with Azithromycin 500mg daily for 5 days and 2% Mupirocin cream locally twice daily for 20 days. On the follow-up visit after a month, the lesion had completely healed and new hairs were growing on the site (Figure 3).

Figure 2: Ulcerated floor after removal of the crust

Figure 3: After one month of treatment

Discussion

Dermatosis Neglecta is caused by the incomplete exfoliation with accumulation of sebum, sweat, keratinocytes and bacteria in a localized area of skin, forming a compact and adherent crust of dirt [2]. The poor skin hygiene may be due to psychiatric illness, neurological deficit, surgical scar, hyperesthesia or even a benign nevus [3]. It needs to be differentiated from Dermatitis Artefacta wherein the lesions are self-inflicted and may be associated with psychiatric diseases. In cases of Dermatitis Artefacta, personality studies suggest an individual who is emotionally immature, introspective, self-centred, with limited interests, who is making a nonverbal attempt to call attention to him/herself [2].

Terra Firma-Forme dermatosis (TFFD), also called Duncan's Dirty Dermatosis was first described by Duncan et al in 1987 [4]. TFFD is a disorder of abnormal keratinization which presents as dirty patches, unaffected by soap and water cleansing but easily cleared with isopropyl alcohol, may also mimic Dermatosis Neglecta. It is distinguished from Dermatosis Neglecta by the history of normal washing and lack of cornflake-like scale [5]. Swabbing with 70% isopropyl alcohol is both diagnostic and therapeutic.

In our patient the hyperaesthesia secondary to the infected varicella lesions on the scalp must have led to wilful neglect of cleansing the affected area although she maintained an overall good hygiene. Gradual accumulation of sweat, sebum and dirt over years led to the development of a tumour like lesion as the patient was careful not to disturb the lesion at any time. The recent onset of pruritus could have been due to secondary infection of the lesion. A high index of suspicion is needed to recognise this condition to avoid unnecessary investigations. Proper counselling of the patient or the caretaker is a must in the management of these patients.

Conflict of interest

There are no conflicts of interest, financial or otherwise, to report.

References

1. Poskitt L, Wayte J, Wojnarowska F, Wilkinson JD. Dermatitis neglecta: unwashed dermatosis. British Journal of Dermatology. 1995 May 1;132(5):827-9.

2. Martin LM, Mendes MF, Takaoka LE, Martin MM, Martin BM. Dermatosis neglecta: A report of two cases. An Bras Dermatol 2010; 85:217-20.

3. Saritha M, Karthikeyan K. Dermatitis neglecta-to be remembered, not neglected! Indian Dermatology Online Journal. 2015;6(2):138-139. doi:10.4103/2229-5178.153024.

4. Duncan W. Christopher Jaime A. Tschen, and John M. Knox. Terra firma-forme dermatosis. Archives of Dermatology 123, no. 5 (1987): 567-569.

5. Choudhary SV, Bisati S, Koley S. Dermatitis neglecta. Indian J Dermatol Venereol Leprol 2011;77:62-3.

The Tumour That Never Was