Introduction
Dermatitis neglecta is a skin condition that occurs as a result of a lack of hygiene. It arises from insufficient cleaning or frictional removal of dirt, which leads to the accumulation of corneocytes, sweat, and sebum. This results in hyper-pigmentation or raised plaque. It is considered a diagnostic challenge because it can mimic other keratotic or pigmented lesions; therefore, it can be wrongly diagnosed. It may be due to a physical disability, neurological deficit, or maybe a psychiatric condition. The accumulation of bacteria, sebum, and sweat forms an adherent crust of dirt on the surface of the skin.
What Is Dermatitis Neglecta?
Dermatitis neglecta is also known as unwashed dermatosis. Improper hygiene and inadequate cleaning can be believed to be the cause. An area that is immobile due to trauma or is experiencing pain, hyperesthesia, or has a history of surgery can lead to insufficient exfoliation. Here the patient denies a lack of cleanliness. Proper cleaning and vigorous rubbing with soap or alcohol can remove the lesion. The patient is thereafter made aware and counseled about the maintenance of hygiene. It is sometimes confused with terra firma forme dermatosis, which occurs due to the maturation delay of corneocytes (topmost cells of the skin) and retention of melanin.
What Are the Causes of Dermatitis Neglecta?
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Dermatitis neglecta arises due to the voluntary or unconscious insufficiency of cleansing of the skin. Although the exact cause is not clear, it is believed that inadequate exfoliation is the factor that leads to the formation of a layer of sweat, sebum, bacteria, and other products. These patients are often unhygienic.
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In most cases, a pre-existing condition may prevent the patient from cleaning the area properly, leading to the formation of the lesion.
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In many cases, the patient may have had a wound in that area, and the pain prevents them from using frictional cleaning leading to a deposit of dirt.
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Some patients with pacemakers do not clean the surrounding area due to fear of damaging the pacemaker.
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Patients with allodynia (nerve pain) may not clean the area for fear of triggering the pain.
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Pityriasis rubra pilaris is a rare inflammatory disorder that is characterized by plaques red in color. Patients with this disorder neglect bathing due to fear of aggravating an inflammatory response.
Who Are the Most Affected?
Dermatitis neglecta does not have an age predilection and can be seen in all ages and all skin types. It can be seen in individuals with a physical or mental disability, trauma, pain, sensory disturbance, or a history of surgery in the area where the lesion is seen.
Dermatitis neglecta can be categorized as a primary psychodermal disorder, as some mental disorders can lead to this condition. Either pain, or fear of pain or lack of self-care due to some psychological disturbances or depression can result in this condition.
What Are the Clinical Features of Dermatitis Neglecta?
Dermatitis neglecta is different from person to person. The location also dramatically varies depending on the underlying cause. Clinical features include:
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It evolves over two to four months.
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Localized hyperpigmentation.
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Verrucous patches.
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Flaky scales.
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It is seen in areas such as genitalia, trunk, surgical sites, and face.
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It can be seen commonly after a pacemaker insertion or a cataract extraction.
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Lesions are mostly asymptomatic; it is only noticed when there is a change in color and starts affecting the patient aesthetically.
How to Diagnose Dermatitis Neglecta?
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Dermatitis neglecta is mostly diagnosed clinically. If a pigmented plaque is observed with flakey scales, especially in patients with a disability, it can be suspected.
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If it is easily removable with isopropyl alcohol, it is extremely likely or indicative of dermatitis neglecta. Alcohol swabs act as a diagnostic and therapeutic tool for dermatitis neglecta.
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Biopsy is not necessary for confirmation. If done, it shows hyperkeratosis, acantholysis, and papillomatosis without any inflammatory infiltrate.
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In some cases, Malassezia yeast has been isolated from the lesions. It is a secondary overgrowth of commensal nature rather than a causative agent.
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Terra firma forme closely resembles dermatitis neglecta; it is differentiated from dermatitis neglecta if the patient exhibits proper hygiene, the lesion does not resolve on soap, water, or alcohol, nor does the lesion present with cornflake-like scales.
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Dermatitis artefacta is a skin disorder where the lesions are produced by the patient due to some underlying psychiatric distress.
How to Treat Dermatitis Neglecta?
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Dermatitis neglecta can be removed by proper cleaning of the area. Using alcohol or soap and water and scrubbing the affected area is effective in most cases. If the case is recognized early, the treatment is easier. This prevents extensive therapeutic interventions and invasive diagnostic needs. In cases in which simple alcohol rubbing is not sufficient keratolytic agents may be required. This breaks down the adherent hyperkeratosis seen in the top layer of the skin.
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Frictional washing with isopropyl alcohol or soap and water.
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The use of keratolytic agents such as (glycolic acid, 20 % urea, and 12 % lactic acid as a combination) can be effective in treating more adamant lesions.
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Use of emollient and daily scrubbing act as an adjuvant.
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It is important to motivate the patient to maintain proper hygiene and prevent a recurrence. The patient should be told that cleaning the affected area is more important than causing detrimental lesion formation. They should be reassured that scrubbing the skin, even in the presence of scarring, after the placement of a pacemaker, or in dysesthesia (long-standing nerve pain) can bring no harm.
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Dermatitis neglecta is challenging to diagnose. Therefore while screening a hyperpigmented lesion that is localized, dermatitis neglecta should be one of the differential diagnoses.
Conclusion
Dermatitis neglecta is a skin condition that arises due to improper hygiene. The deposition and accumulation of sebum, sweat, and corneocytes lead to the formation of the lesion. The disease is otherwise asymptomatic and resolves when cleaned with soap and water. It does not require extensive treatments, and the patient should be encouraged to maintain proper hygiene so that the lesion does not recur.
