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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 5 | Page : 595-596 |
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| Pacemaker site dermatitis neglecta: A diagnostic dilemma unravelled by dermoscopy |
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Farheen Begum, Akash Agarwal, Bikash R Kar
Department of Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| Date of Web Publication | 29-Dec-2022 |
Correspondence Address:
Akash Agarwal
Department of Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_1043_21
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How to cite this article:
Begum F, Agarwal A, Kar BR. Pacemaker site dermatitis neglecta: A diagnostic dilemma unravelled by dermoscopy. Indian J Dermatol 2022;67:595-6 |
How to cite this URL:
Begum F, Agarwal A, Kar BR. Pacemaker site dermatitis neglecta: A diagnostic dilemma unravelled by dermoscopy. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 6];67:595-6. Available from: https://www.e-ijd.org/text.asp?2022/67/5/595/366091 |
Sir,
A 52-year-old male presented with an asymptomatic reddish patch near the implanted pacemaker site over the left upper chest region since 2 months. There was a history of surgical pacemaker implantation 1 year ago. Dermatological examination revealed a single circular erythematous greasy plaque of size 2 × 3 cm present in the infraclavicular region just medial to the pacemaker. Just above the pacemaker, a linear collection of greasy black adherent scales was also present [Figure 1]a. Initially, differential diagnosis considered were allergic contact dermatitis to the pacemaker metal (Pacemaker dermatitis) and autonomic denervation dermatitis following possible transection of cutaneous infraclavicular nerves. The patient was planned for a biopsy, but was reluctant for any invasive procedure near the pacemaker site. He was advised emollients and antihistamines for 15 days. | Figure 1: (a) A circular erythematous greasy plaque (size 2 × 3 cm) present medial to pacemaker in the infraclavicular region. Just above the pacemaker, a linear collection of greasy black adherent scales observed. (b) Upon cleaning with alcohol swab, the scales were easily removable. The area above the pacemaker revealed white atrophic area suggestive of pacemaker incision site while the erythematous plaque was still persistent medially. (c) Two weeks follow-up: resolution of erythematous plaque medial to the pacemaker site
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In the follow-up, no improvement was noted. The patient was convinced for a dermoscopic examination which revealed cornflake like brown scales arranged irregularly in the background of erythema [Figure 2]. The dermatoscopic features and hesitancy of allowing contact over the eczematous site for dermoscopy hinted towards a possibility of dermatitis neglecta. The area was then soaked with normal saline gauze and cleaned with alcohol, and to our surprise, the scales were easily removable. Following removal of the scales, the area above the pacemaker revealed white atrophic area suggestive of pacemaker incision site while the erythematous plaque was still persistent medially [Figure 1]b. The patient was enquired regarding hygiene of the particular area wherein he revealed his fear of displacing the pacemaker by any kind of manipulation. The patient was subsequently counselled regarding the diagnosis and was asked to regularly wash and clean the area along with application of emollients. During a review follow-up after 2 weeks, the erythematous plaque also resolved completely [Figure 1]c. A final diagnosis of pacemaker site dermatitis neglecta leading to secondary eczematous reaction was made. | Figure 2: Dermoscopy using a Dermlite 4 dermoscope with an Iphone X connector: cornflake-like brown scales arranged irregularly in the background of erythema
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Dermatitis neglecta, first introduced by Poskitt et al.[1] in 1995, describes a localised area of hyperkeratosis and hyperpigmentation resulting from inadequate cleaning of a particular area of the body. The pathogenesis lies in the insufficient cleansing and hygiene in an area of immobility, pain, hyperesthesia, prior trauma, and surgery leading to inappropriate exfoliation of skin and accumulation of sebum, sweat, keratin, and other dirt.[2] Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. Treatment includes counselling and encouraging appropriate hygiene. For more resistant and verrucous lesions, combination of a keratolytic agent with an emollient may be required.
Pacemaker site allergic contact dermatitis to pacemaker metal although rare has been reported in literature. The absence of itch and lack of erythematous plaque exactly over the pacemaker ruled out this possibility.[3] Given the site of incision being exactly above the pacemaker and distribution of cutaneous infraclavicular nerves being vertically downwards in that region, a possibility of denervation dermatitis was also considered. but resolution following removal of scales and use of emollients reduced the likelihood of this possibility.[4]
Dermatitis neglecta is often a misdiagnosed and underreported as dermatoses. Dermatologists need to be aware of this condition for early diagnosis and management. The rarity of the condition and unusual site along with dermatoscopic-aided diagnosis prompted the present report.
Declaration of patient consent
Informed consent for publication taken from the patient's parents.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Poskitt L, Wayne J, Wojnarowska F, Wilkinson JD. Dermatosis neglecta: Unwashed dermatosis. Br J Dermatol 1995;132:827-9.  |
| 2. | Maldonado RR, Duran-McKinster C, Tamayo-Sanchez L, Orozco-Covarrubias ML. Dermatosis neglecta: Dirt crusts simulating verrucous nevi. Arch Dermatol 1999;135:728-9. |
| 3. | Oliveira MF, Piccini JP, Atwater BD, Atwater AR. Pacemaker contact dermatitis: Clinical and histopathologic description. Dermatitis 2013;24:91-2. |
| 4. | Bose S, Joseph J. Autonomic denervation dermatitis following saphenous vein grafting: A case report. Int J Dermatol 2021. doi: 10.1111/ijd. 15990. Online ahead of print. |
[Figure 1], [Figure 2] |
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