Poskitt et al. initially recognized and described dermatitis neglecta, commonly referred to as unwashed dermatosis, in the year 1995.^[1] Dermatitis neglecta is a clinical illness that is rarely recognized because of poor cleaning, forming an adherent crust of dirt.^[2] It mainly involves the trunk and flexures, presenting as hyperpigmented verrucous plaque. Water along with soap may be employed to remove these lesions. ^[3,4] It is frequently misdiagnosed because it resembles other hyperpigmented disorders.^[4] Although this dermatosis is a widespread dermatological condition, there is a dearth of literature on it, and it is frequently misdiagnosed or underdiagnosed. In this study, we described the clinical and epidemiological features of Dermatitis neglecta in patients attending dermatology OPD as well as inpatients of our institute.

Settings and Design: This prospective observational study's objective was to ascertain clinical as well as epidemiological spectrum of Dermatitis neglecta encountered at a tertiary care hospital in Western Uttar Pradesh. Each clinically diagnosed instance (30) of Dermatitis neglecta, who attended dermatology outpatient department, between Jan 2019 to Oct 2019 had been involved in this investigation. Every case had a thorough history that included information on age, gender, duration of stay. To ascertain the region of involvement, lesion morphology, as well as lesion pattern, a comprehensive clinical examination was conducted. MS Excel had been utilized to compile the data, while SPSS version 20 was employed for analysis.

In our study mean age of onset was 52 years with age of the patients ranging from 5-56 years. Male‑to‑female ratio was 3:7. Majority of the cases (80%) presented during the postoperative period. All the patients had a history of inadequate cleansing, improper hygiene and self-neglect (100%). The probable reason for neglect was pain and apprehension following post-surgery in 12 patients; immobility in 8 patients; herpes zoster in 4 patients; post radiation in 3 patients; secondary to psychiatric illness in 2 patients and physical barrier in the form of a cast in 1. The duration of onset varied from 2 to 6 weeks. The clinical lesions included asymptomatic localized hyperpigmented verrucous plaque. Most common location of dermatitis neglecta was the extremities (53.3%), followed by trunk (26.6%), face (16.6%), genitals (3.5%). Other dermatological examinations were normal. The lesions could be wiped off with soap and water or spirit swabs in all our patients (100%).

Figure 1

1. a) Hyperpigmented verrucous plaque over Right leg – post leukocytoclastic vasculitis
2. b) Spirit swab test positive

Figure 2

1. a) Dermatitis neglecta with underlying keloid
2. b) Normal looking – skin after cleansing with spirit swab

Table 1: Epidemiological Data

Dermatitis neglecta is a quite rare condition that occurs in routine clinical settings^.[1] The etiology of this entity has not been thoroughly investigated. The triggering elements are thought to consist of inadequate cleanliness and poor hygiene in a painful area, immobility, hyperesthesia, previous trauma, and post-surgery, which results in insufficient skin exfoliation^.[5,6] These localized verrucous plaques with hyperpigmented patches or adherent, corn flake-like scales are most likely caused by keratin, perspiration, sebum, and other dirt buildup^.[5,7] When lesion is thoroughly cleaned with soap along with water or gauze soaked in alcohol, it resolves completely. Patients should receive counselling and encouragement to keep the affected area hygienic, as this is more useful than harmful. Cleaning the afflicted region every day with water along with soap or alcohol is usually enough. For instances that are resistant Emollients as well as keratolytic agents can be used^.[3]

When making a differential diagnosis for any hyperpigmented localized lesions, dermatitis neglecta should be considered, particularly in individuals with disabilities. A total of 30 patients with dermatitis neglecta were evaluated including 21 females (73%) and 9 males (27%) with male to female ratio of 3:7. The mean age had been 52years, with a range of 5 to 56years. A spirit swab as well as mild soap water were employed to gently clean the region, and the patients' typical clinical features were employed to make the diagnosis. Twenty-three (77%) of thirty individuals were from rural regions, while the other seven (23%) were from metropolitan areas. The disease lasted for 2-6weeks, with a mean of 4weeks. Every patient (100%) had cosmetic concerns when they first arrived. Fear of pain & apprehension following post-surgery was the predominant reason for neglect in 12 patients (40%). In remaining cases 8 patients (27%) had immobility, herpes zoster in 4 patients (13%), post radiation in 3 patients (10%), secondary to psychiatric illness in 2 patients (7%), Physical barrier in the form of cast in one (3%). All age groups as well as both sexes are affected by dermatitis neglecta, that can appear anywhere on the body but is typically restricted to hard-to-reach regions. Though, in this case study we discovered that extremities were predominant location affected in 16 patients (53%). Other involved sites were trunk (27%), face (17%), genital (1%) areas.

Several differential diagnoses must be investigated, with TFFD being a special mention. Terra firma forme dermatosis resembles dermatitis neglecta, with diagnostic indicators including proper hygiene, absence of cornflake-like scales, along the unclean patch's resistance to cleansing with soap & water. ^{[8,9,10,11,12,13]} Dermatitis artefacta is a factitious condition characterized by lesions that are self-induced or exacerbated by the patient, stemming from underlying psychological issues^.[14] Confluent as well as reticulated papillomatosis of Gougerot and Carteaud typically manifests as hyperkeratotic or verrucous grey-brown papules that merge into central confluent plaques, exhibiting a reticulated pattern at the periphery. It is predominantly located on the central along with neck, upper trunk, and axilla in adolescents and young adults, and is not associated with hygiene practices^.[15] Entities such as pityriasis versicolor, verrucous naevi, post inflammatory hyperpigmentation, acanthosis nigricans, dirty neck of atopic dermatitis, frictional hyperkeratosis, and numerous varieties of ichthyosis are the other differentials to be excluded^{. [3,16]} Several case reports and case series have been published. Saha A et al^.,[3] reported dermatitis neglecta in a post operative patient. 72.7% of patients with dermatitis neglecta in a case study by Ghosh SK et al. had a psychiatric disorder^.[16] We underestimate the actual prevalence of this condition, as most patients remain asymptomatic and are unaware of the underlying pathological characteristics of this seemingly harmless entity.

An underreported aesthetic concern is dermatitis neglecta. In individuals with a history of discomfort or impairment and hyperpigmented verrucous localized lesions, dermatitis neglecta should be taken into consideration. Invasive diagnostic along treatment procedures are avoided when cases and their underlying causes are identified early. Spirit swab test is both diagnostic and therapeutic. But many at-time vigorous rubbing cannot be done due to recent surgery/pain at the affected area. However, patients are often not convinced by a simple spirit swab test. Misdiagnosis rate will be reduced if medical professionals are properly informed. Additionally, larger sample sizes are required in investigations to determine any underlying causes.

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13. Erkek, E., et al. “Terra Firma‑Forme Dermatosis.” Indian Journal of Dermatology, Venereology and Leprology, vol. 78, May 2012, p. 358.
14. Kwon, E. J., et al. “Dermatitis Artefacta.” Journal of Cutaneous Medicine and Surgery, vol. 10, no. 2, Mar. 2006, pp. 108–13.
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16. Ghosh, S. K., et al. “Clinical Profile of Dermatitis Neglecta with Special Emphasis on Psychiatric Comorbidities: A Case Series of 22 Patients from Eastern India.” Indian Journal of Psychiatry, vol. 64, no. 6, Nov. 2012, p. 599.