Dermatology Online Journal

Dermatosis neglecta: A series of case reports and review of other dirty-appearing dermatoses
Jennifer L Lucas MD¹, Robert T Brodell MD^1,2, Steven R Feldman MD PhD³
Dermatology Online Journal 12 (7): 5

1. North Eastern Ohio Universities College of Medicine, Rootstown, Ohio
2. Case Western Reserve University School of Medicine
3. Wake Forest University School of Medicine, Winston-Salem, North Carolina

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Abstract

Localized scaling and hyperpigmentation is a common finding and often a diagnostic and therapeutic challenge. Dermatosis neglecta (DN) represents a failure to adequately clean or scrub the skin, often in an area of hyperesthesia or prior trauma. We identified five cases of DN in two clinical practices in just the past few years. The condition is characterized by scrupulous avoidance of scrubbing, leading to a buildup of hyperpigmented, adherent, cornflake-like scales. An alcohol swabbing provided diagnosis and prompt clearing. Washing with soap and a washcloth also often leads to clearing. Dermatosis neglecta should be considered in the differential diagnosis of hyperpigmented scale; alcohol swabbing can serve as a diagnostic and therapeutic tool.

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Localized scale and hyperpigmentation are identified in numerous dermatologic conditions and are associated with both diagnostic and therapeutic challenges. Failure to adequately clean or scrub the skin, often in an area of hyperesthesia or prior trauma, can produce dermatosis neglecta (DN) [1, 2]. This has similarities to dermatitis artifacta (DA) although in the latter condition the lesions are associated with acts of commission whereas in DN the dermatitis is associated with acts of omission [1]. Dermatosis neglecta may be more common than previously realized; we have identified five cases in two clinical practices in just the past few years. The condition is characterized by scrupulous avoidance of scrubbing the involved area, leading to a buildup of hyperpigmented, adherent, cornflake-like scales. Washing with soap and a washcloth can lead to clearing. The scale, however, can be more promptly removed with alcohol swabbing, which also serves as a diagnostic tool.

Clinical synopsis

Case 1

Figure 1A	Figure 1B
Figure 1A. Cornflake-like scale surrounding the pacemaker after scrupulous avoidance of cleansing Figure 1B. After treatment with ketoconazole cream

An 84-year-old man presented with a 6-year history of a persistent, asymptomatic, brown, adherent scale around the site of a pacemaker, which occurred within 1 year after its insertion. The patient avoided scrubbing the area because he was afraid he might damage the pacemaker. Examination revealed patchy broad, brown, waxy scale localized to the right chest and surrounding the pacemaker in a 20-cm diameter area with each individual scale resembling a cornflake (Fig. 1A). The skin overlying the pacemaker was spared, which could potentially be explained by the presence of friction of clothing in contact with the skin overlying the protruding pacemaker. There were no other areas of hyperpigmentation. Histopathology of the skin revealed epidermal atrophy with diminution of rete pegs, thick basketweave hyperkeratosis, and an underlying sparse focally lichenoid inflammatory infiltrate. Numerous yeast forms representing pityrosporon were present throughout the stratum corneum. Vigorous scrubbing with a gauze pad removed the scale revealing underlying normal skin with points of bleeding. Because of the uncomfortable nature of this therapy and the large area of involvement, treatment was initiated with ketoconazole cream BID and the instruction to wash the area with soap and water daily using a washcloth to induce light friction. Complete resolution occurred over the next 2 months (Fig. 1B).

Case 2

Figure 2
Cornflake-like scale involving the mastectomy site after the patient avoided touching or cleansing the area for months

A 77-year-old woman presented with an asymptomatic rash involving the right chest overlying the area of a previous mastectomy. She admitted to strict avoidance of washing this area with a washcloth, her hands, or soap and water because of hyperesthesia of the site. Physical examination revealed a 30-cm diameter area of brown, dry, adherent, cornflake-like scale in a patchy distribution localized to the right chest and overlying the site of the mastectomy (Fig. 2). The KOH prep was negative. Treatment was initiated with Cetaphil® soapless cleanser and daily light scrubbing of the area to promote exfoliation. The condition cleared completely within 1 month.

Case 3

Figure 3
Cornflake-like scale of the upper and lower eyelids that occurred after the patient avoided washing the eyelids for months

A 20-year-old woman presented with a 4-5 month history of pruritic scaling of the upper and lower eyelids bilaterally. After a period of rubbing and scratching the lids became tender. Initially treated for eczema and contact dermatitis, her itching and eruption resolved. She scrupulously avoided touching the lids or washing with a washcloth because the lids were tender and she was told rubbing and scratching would irritate her eczema. On examination, the scales were noted to have a brown, waxy, cornflake-like appearance (Fig. 3). Treatment was initiated with 5-percent glycolic acid cream and 12-percent lactic acid cream BID for 2 weeks. After 6 weeks she appeared to be 50 percent improved.

Case 4

Figure 4
Cornflake-like scale of the left forehead overlying the site of prior surgery and radiation

A 52-year-old man with a history of a brain tumor presented with asymptomatic brown scale on the left forehead overlying the area of prior surgery and radiation. Because the area was hyperesthetic and because he feared damaging his brain he was afraid to wash or even touch this skin. On examination there was dry, brown, adherent, 2-6 mm, cornflake-like scale, in a patchy distribution localized to the area of the left forehead near the hairline (Fig. 4). On histopathology, mild acanthosis and marked hyperkeratosis were present. The patient was instructed to lightly scrub the area daily with soap and water. After 1 week there was no improvement. Lightly scrubbing with a washcloth, soap, and water led to resolution of the rash in 2 months.

Case 5

Figure 5A	Figure 5B
Figure 5A. Confluent cornflake-like scale of the facial area Figure 5B. Alcohol swabbing of the left forehead reveals underlying normal skin

A 47-year-old woman presented with a 6-month history of brown discoloration of the face. She underwent a facial peel 6 months prior and reported being instructed not to use a washcloth on the face. She continued to avoid washing the area even after developing scale. She assumed that the scale was a prolonged reaction to the peel. On examination there was confluent, brown, waxy, cornflake-like scale on the face (Fig. 5A). After baseline photography, alcohol swabbing the area completely cleared the scale and revealed underlying normal skin (Fig. 5B). The patient was instructed to wash her face with a washcloth and soap twice a day. This led to gradual clearing over 3-4 weeks.

Discussion

Dermatosis neglecta, a condition that arising from inadequate frictional cleansing, presents both diagnostic and therapeutic challenges. Over a short time, we were able to identify five cases in two private practices. We believe this is an underestimate of the true prevalence of this condition because the patients have no symptoms and are often more accepting of this appearance than would be anticipated. Clinically, patches of brown cornflake-like scale develop in patients who scrupulously avoid washing an area of skin for a variety of reasons.

Once patients are instructed to wash the area with soap and water using a washcloth to provide friction, clearing occurs within weeks to months. An isopropyl alcohol swab is a cost-effective, painless diagnostic test that doubles as treatment. Skin biopsy can generally be avoided in these cases. The pathophysiology is currently unknown but appears to involve insufficient exfoliation leading to a build up of adherent scale. These localized scaly patches are probably areas of the stratum corneum where corneocytes, sebum, sweat, and bacteria have accumulated [2]. Pityrosporum orbiculare was noted in case 1 and may represent yeast overgrowth in a conducive environment rather than a causative factor. Isopropyl alcohol or soap and water over time can penetrate and loosen scale and lead to clearance [1, 2, 3, 4].

Figure 6A	Figure 6B

Figure 7A	Figure 7B
Figure 6A. Terra firma forme dermatosis. An 18 year old female who denied inadequate cleansing presented with hyperpigmented patches minimally improved with soap and water scrubbing. Figure 6B. Alcohol swabbing reveals normal underlying skin Figure 7A. Terra firma forme dermatosis. This 17-year-old male who denied inadequate cleansing presented with hyperpigmented patches posterior to the lateral malleolus unresponsive to soap and water cleansing. Figure 7B. Alcohol swabbing of the center of the lesion reveals underlying normal skin.

There are several conditions described in the literature with similar clinical features (Table 1). Terra firma forme dermatosis is recognized as dirty patches unaffected by soap and water cleansing but easily cleared with isopropyl alcohol (Figs. 6A, 6B, 7A, 7B). It is distinguished from DN by the history of normal washing and lack of cornflake-like scale. Histopathologically, PAS positive yeast can be present. Speculation into the pathophysiology of this condition include incomplete maturation of squames with retention of melanin and initial inadequate cleansing with buildup and compaction of scales and dirt [3, 4, 5]. Confluent and reticulated papillomatosis of Gougerot and Carteaud has a velvety appearance and is commonly associated with Pityrosporon orbiculare. It is distributed on the central trunk and is not related to cleansing. Confluent and reticulated papillomatosis has a negative alcohol swab test [6]. Other conditions in the differential diagnosis include atopic dermatitis with post inflammatory hyperpigmentation, X-linked ichthyosis, acanthosis nigricans, frictional asymptomatic darkening of the extensor surfaces, and idiopathic deciduous skin () [7, 8, 9, 10].

When there is a history of neglect leading to improper exfoliation of the stratum corneum, daily light scrubbing with soap and water is essential. Lightly scrubbing of the involved area with isopropyl alcohol is an inexpensive, effective therapy. For those patients with more severe or resistant lesions, or for those requiring a longer course of treatment, we recommend a regimen of a keratolytic agent, an emollient, and daily light frictional scrubbing to elicit clearing of the scales. We have found urea 20 percent lotion, glycolic acid 5 percent lotion, and lactic acid 12 percent lotion to be effective when coupled with daily light scrubbing with a soapless cleanser.

Dermatosis neglecta is an underreported, asymptomatic, but esthetically bothersome dermatosis. Dermatologists need to be aware of this condition that can be clinically diagnosed and effectively and inexpensively treated.

References

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