Dermatitis neglecta

Author(s): Thomas Stewart, General Practitioner, Sydney, Australia. DermNet New Zealand Editor in Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. November 2017.


What is dermatitis neglecta?

Dermatitis neglecta, first described by Poskitt and colleagues in 1995, is a dermatological disorder that results from voluntary or unconscious inadequate frictional cleansing of the skin [1]. 

Dermatitis neglecta

Who gets dermatitis neglecta?

Dermatitis neglecta has been reported in all ages and skin types, but most commonly occurs in individuals with a physical or mental disability, or sensory disturbance, pain, trauma, or previous surgery in the affected area [2–5]. It is believed to be quite common, although there are only a handful of cases in the literature. This is likely attributable to underreporting and misdiagnosis.

What causes dermatitis neglecta?

The exact pathogenesis of dermatitis neglecta remains unclear. Inadequate exfoliation of the skin leads to the accumulation of sebum, sweat, keratin, bacteria, and other breakdown products forming a compact crust of dirt [6].

Patients often deny a lack of cleanliness.

What are the clinical features of dermatitis neglecta?

Clinical features of dermatitis neglecta include:

  • Localised hyperpigmented patches or verrucous plaques with adherent, flaking scale
  • Evolution over 2–4 months
  • Involvement of trunk, genitalia, limbs, face, and surgical sites (eg after pacemaker insertion or cataract extraction) [2–8].

Lesions are generally asymptomatic but may be cosmetically bothersome for some patients.

What is the differential diagnosis for dermatitis neglecta?

Dermatitis neglecta is mimicked by other localised hyperpigmented skin lesions. The main differential is terra firma-forme dermatosis (Duncan's dirty dermatosis), which is due to a delay in maturation of corneocytes (dead keratin-filled squamous cells in the epidermis) [9]. Other conditions to consider in differential diagnosis include:

How is dermatitis neglecta diagnosed?

Dermatitis neglecta should be suspected clinically with any localised hyperpigmented patch or plaque with a flake-like scale, especially in those with disability.

  • Successful removal of crusts with isopropyl alcohol is highly suggestive [2,3].
  • Biopsy is usually not necessary. It shows orthokeratotic hyperkeratosis, papillomatosis, and mild acantholysis, without an inflammatory infiltrate [10].
  • Malassezia yeast has been isolated from some lesions but likely represents commensal overgrowth rather than a causative factor [3].

What is the treatment for dermatitis neglecta? 

The patient can be reassured that no harm will be caused by gently scrubbing the skin, even where there is scarring, dysesthesia, or a pacemaker.

  • Frictional washing of the affected area with isopropyl alcohol or soap and water generally produces clearing in days or weeks to months [2,3]
  • For more severe or resistant lesions, a regimen of a keratolytic agent (for example, 20% urea, 5% glycolic acid, 12% lactic acid as a combination lotion), emollient, and daily scrubbing may be useful [2,3]

What is the outcome of dermatitis neglecta?

Patients should be encouraged to wash their skin at least twice weekly [2,3]. Associated disorders (eg, chronic pain) should be assessed and managed. Dedicated daily light scrubbing with soap and water or isopropyl alcohol may provide effective prophylaxis in high-risk cases [2,3].

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References

  1. Poskitt L, Wayne J, Wojnarowska F, Wilkinson JD. Dermatitis neglecta: unwashed dermatosis. Br J Dermatol. 1995; 132: 827–39. DOI: 10.1111/j.1365-2133.1995.tb00736.x. Journal
  2. Saha A, Seth J, Sharma A, Biswas D. Dermatitis neglecta -- a dirty dermatosis: report of three cases. Indian J Dermatol. 2015; 60: 185–7. doi:10.4103/0019-5154.152525. PubMed Central
  3. Lucas, JL, Brodell RT, Feldman, SR. Dermatosis neglecta: A series of case reports and review of other dirty-appearing dermatoses. Dermatology Online Journal. 2006; 12(7): 5. Journal
  4. Sanchez A, Duran C, de la Luz-Orozco M, Saez M, Maldonado RR. Dermatosis neglecta: a challenge diagnosis. Dermatol Pediatr Lat 2005; 3: 45–7.
  5. Qadir SNR, Ejaz A, Raza N. Dermatosis neglecta in a case of multiple fractures, shoulder dislocation and radial nerve palsy in a 35-year-old man: a case report. J Med Case Reports 2008; 2: 347. doi.org/10.1186/1752-1947-2-347. PubMed
  6. Ruiz-Maldonado RR, Duran-McKinster C, Tamayo-Sánchez L, Orozco-Covarrubias ML. Dermatosis neglecta: dirt crusts simulating verrucous nevi. Arch Dermatol. 1999; 135: 728–9. Journal
  7. Sasaya EMK, Gislandi C, Trevisan F. Dermatosis neglecta. An Bras Dermatol. 2015; 90(3 Suppl 1): DOI: 10.1590/abd1806-4841.20153656. PubMed Central
  8. Panda M, Patro N, Saman S, Arora S. Dermatitis neglecta as a complication after cataract surgery. Indian J Ophthalmol 2016; 64: 231–2. DOI: 10.4103/0301-4738.181751. PubMed Central
  9. Martin-Gorgojo A, Alonso-Usero V, Gavrilova M, Jordá-Cueva E. Dermatosis neglecta or terra firma-form'e dermatosis. Actas Dermosifiliogr. 2012; 103: 932–4. Journal
  10. Park JM, Roh MR, Kwon JE, et al. A case of generalized dermatitis mimicking psoriasis vulgaris. Arch Dermatol. 2010; 146: 1050–1. DOI: 10.1001/archdermatol.2010.228. PubMed

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