Dermatitis Neglecta Presenting as Smegmolith in Healthy Adult Male

INTRODUCTION

Dermatitis neglecta (DN) is a condition resulting from progressive accumulation of sebum, sweat, dirt, corneocytes and debris due to inadequate cleansing. It may present as hyperpigmented patches or warty/verrucous plaques and is mostly misdiagnosed.^[1] Underlying psychiatric and neurological disturbances predispose an individual to have DN. Diagnosing the condition can actually prevent unnecessary therapeutic and diagnostic procedures. Smegmoliths are calcareous concretion in the smegma which is more common in paediatric age group.

We report a case of smegmolith in an adult occurring as a manifestation of DN.

CASE REPORT

A 45-year-old male patient presented with painful swelling over glans penis for the past 4 months. On examination, there were multiple whitish finger like projections having a stuck-on appearance over the glans penis [Figure 1]. Smegmolith, pseudoepitheliomatous keratotic micaceous balanitis (PKMB) and genital verruca were considered as the differential diagnoses. The lesions were wiped with a saline soaked gauze and removed completely showing a normal underlying skin [Figure 2]. He did not have any psychiatric comorbidity. However, the patient gave history of not retracting his foreskin due to pain.

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Figure 1:

Multiple whitish fingers like projection over glans penis.

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Figure 2:

Complete removal of lesions with normal underlying skin on wiping with saline soaked gauze.

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The patient did not maintain proper genital hygiene in the form of daily cleaning. He did not have any risky sexual behaviour.

DISCUSSION

Poskitt et al. was the first to define the term DN also known as ‘Unwashed dermatitis.’^[2] The exact aetiology of this condition is not clearly known. However, lack of hygiene and inadequate cleansing in areas of hyperesthesia, pain, immobility, trauma and surgery resulting in insufficient exfoliation of skin are known precipitating factors.^[1] PKMB is a rare penile condition usually seen in elderly more common in uncircumcised men. The presenting lesions are hyperkeratotic plaques with thick micaceous scales over glans penis which is generally asymptomatic.^[3] The important differentiating feature of PKMB from DN is that even with vigorous cleansing the lesions cannot be removed. The other differential is genital wart which is usually skin coloured warty lesions over glans and are rarely symptomatic (itching/pain/discomfort). These lesions also cannot be removed by extensive cleansing. Smegmoliths are calcareous concretions in the smegma which are not commonly seen in adults. They are usually seen in children with phimosis resulting in improper cleansing. Management of DN includes thorough cleansing of lesions with saline soaked gauze and maintaining proper self-hygiene. The patient should also be effectively counselled regarding adequate hygiene. Some reports suggest that patients having underlying psychiatric illness are unable to take care of general skin hygiene which increases the risk of DN. However, in our case, thorough psychiatric evaluation was done and the patient had no underlying psychiatric illness. As reported by Singh et al. DN is uncommonly associated with psychiatric disorders.^[4]

CONCLUSION

DN presenting as smegmolith in adults with no underlying psychiatric illness is a rare condition and has not been reported. Adequate awareness among the clinicians can prevent misdiagnosis and can be effectively and inexpensively treated.