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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.85 no.2 Rio de Janeiro Mar./Apr. 2010
Dermatosis neglecta: a report of two cases*
Ligia Márcia Mario MartinI; Mauro Filgueiras MendesII; Lúcia Emiko TakaokaII; Manoela Mário MartinIII; Beatris Mário MartinIV
Masters Degree in Clinical Medicine. Londrina, PR, Brazil
IIDermatologist, São Jerônimo da Serra, PR, Brazil
IIIMedical student, Pontifical Catholic University (PUC), Curitiba, PR, Brazil
IVMedical student, Federal University of Paraná (UFPR), Curitiba, PR, Brazil
Few cases of dermatosis neglecta have been reported in the medical literature, although the diagnosis is well-known to dermatologists. Recognizing this condition avoids unnecessary, aggressive diagnostic and therapeutic procedures. This case report discusses two cases of this condition in female patients in whom the dermatosis developed as a result of deliberate or unconscious neglect of personal hygiene.
Keywords: Adolescent; Adult; Female; Hygiene
Dermatitis artefacta is a condition that consists of lesions produced or aggravated by the actions of the patient and is associated with psychiatric diseases. 1 Dermatosis neglecta results from the accumulation of sebum, sweat, corneocytes and bacteria in a localized area of skin, forming a compact and adherent crust of dirt. 2
Few cases have been reported in the literature; however, recognition of this condition and its causes is important in order to avoid aggressive, unnecessary diagnostic and therapeutic procedures.1,2 Here, we report on two cases in which the clinical condition of the patients developed as the result of intentional or unconscious neglect of personal hygiene.
Case 1: A female patient, 23 years of age, a rural worker from Marquinhos, Paraná, reported darkcolored lesions on her face that had first appeared four months previously. She had no other associated symptoms. Her condition deteriorated progressively, becoming unsightly. She had not washed her face since she first developed the condition and denied having undergone any previous treatment. Dermatological examination showed desquamative, greasy, hyperchromic lesions that were easily removed to reveal areas of normal skin. The condition covered the patients entire face, particularly the forehead and malar region, extending onto the neck and chest (Figure 1). Anatomopathological examination revealed intense hyperkeratosis with a strong presence of spores. The patient was given instructions regarding her personal hygiene and advised to use a 5% urea cream. When the patient returned 30 days later, no improvement was found. The crusts were removed mechanically (Figure 2), the area was cleaned and the patient was instructed to use a salicylic acid shampoo as well as miconazole lotion and a salicylic acid and sulphur soap. The patient strongly resisted to having the crusts removed and insisted on being granted sick leave from work. Psychological evaluation was requested and the patients family was given instructions regarding her personal hygiene. The patient was granted sick leave from work. She returned 30 days later at which time the condition had completely regressed (Figure 3).
Case 2: A female patient, 23 years old, a housewife born in Nova Fátima, currently living in Pinhal, Paraná. She reported lesions on her face and neck over the past 8 years. Dermatological examination showed greasy scales and crusts sticking to her face and neck, which were easily removed, revealing areas of normal skin (Figure 4). The patient was counselled with respect to her personal hygiene and instructed to use desonide cream 0.05% and ciclopirox olamine cream. When the patient returned for follow-up 30 days later, the lesions had partially improved (Figure 5). The patients husband appeared quite concerned about his wifes condition; however, the patient was resistant to the recommendations given. The affected area was cleaned and the crusts removed, resulting in a significant improvement in the appearance of the lesions, which displeased the patient. Thirty days later, there was a mild improvement in the lesions (Figure 6). The patient retains her secondary emotional gain.
In cases of dermatitis artefacta, personality studies suggest an individual who is emotionally immature, introspective, self-centered, with limited interests, who is making a nonverbal attempt to call attention to him/herself. 1,3 Stein 4 classifies dermatitis artefacta as an obsessive-compulsive disorder.
Stressful events prior to the onset of the condition may act as triggering or aggravating factors.1,5 Young women comprise the majority of patients.1
These patients tend to be reluctant to believe the diagnosis or become indignant when confronted by the physician with respect to the etiology of their disease. Confronting the patient at this time may be a counterproductive measure. The negative feelings that the patients show when the healthcare team attempts to provide care for them hamper compliance and response to treatment.1,6 Interdisciplinary collaboration between dermatologists, dermatopathologists, psychologists and psychiatrists is important in managing these cases in order to achieve optimal results. 7
In case 1, the triggering factor appears to have been the patient starting work as an agricultural worker in a sugarcane plantation and the secondary gain obtained was the granting of sick leave from work, which resulted in satisfactory compliance with the proposed therapy. In addition, the relationship between the patient and the healthcare team was preserved. The patient agreed to undergo psychological evaluation.
In case 2, the aggravating factor may have been the patients marriage and the secondary gain appears to have been the great commotion that the patient provoked in her family, principally her husband. This patient was more reluctant to follow the recommended therapeutic measures. She failed to comply with the proposed treatment and appeared to experience great difficulty in following the guidance given to her by the healthcare team with respect to her personal hygiene.
1. Poskitt I, Wayte J, Wojnarowska F, Wilkinson JD. 'Dermatitis neglecta': unwashed dermatosis. Br J Dermatol. 1995;132:827-9. [ Links ]
2. Ruiz-Maldonado R, Durán-McKinster C, Tamayo- Sánchez L, Orozco-Covarrubias ML. Dermatosis neglecta: dirt crusts simulating verrucous nevi. Arch Dermatol. 1999;135:728-9. [ Links ]
3. Lyell A. Cutaneous artifactual disease. A review, amplified by personal experience. J Am Acad Dermatol.1979;1:391-407. [ Links ]
4. Stein DJ, Hollander E. Dermatology conditions related to obsessive-compulsive disorder. J Am Acad Dermatol. 1992;26;237-42. [ Links ]
5. Boralevi F, Marco-Bonnet J, Lepreux S, Buzenet C, Couprie B, Taïeb A. Hyperkeratotic head and neck Malassezia dermatosis. Dermatology. 2006;212:36-40. [ Links ]
6. Gupta MA, Gupta AK. Psychodermatology: an update. J Am Acad Dermatol. 1996;34:1030-46. [ Links ]
7. Kwon EJ, Dans M, Koblenzer CS, Elenitas R, James WD. Dermatitis artefacta. J Cutan Med Surg. 2006;10:108-13. [ Links ]
Mailing Address: Received on August
11th, 2008. *
Study performed at the Dermatology Clinic of the Associação Filantrópica
Humanitas, São Jerônimo da Serra, PR, and in a private clinic in
Londrina, PR, Brazil.
Ligia Márcia Mario Martin
Rua Paranaguá, 539, ap. 1104, Centro
86020 030 Londrina PR, Brasil
Tel./fax: 43 3323-5206 43 3323-4475
43 9993-9528 43 3344-4038
Approved by the Editorial Board and accepted for publication on December 8th, 2008.
Conflict of interest: None
Financial funding: None
Received on August
* Study performed at the Dermatology Clinic of the Associação Filantrópica Humanitas, São Jerônimo da Serra, PR, and in a private clinic in Londrina, PR, Brazil.