A 30-year-old man presented with a 6 year history of recurrent, multiple asymptomatic raised lesions over his back and bilateral upper limbs. He had been treated repeatedly for a case of recurrent boils with oral and topical antibiotics. Some of the lesions had healed spontaneously leaving behind unsightly scars. The patient denied any history of associated fever, chronic cough, weight loss, and drug intake prior to the onset of lesions. There was no recognized contact with tuberculosis patients. General and systemic examination was essentially normal. Dermatological examination revealed the presence of multiple, well-defined, hyperpigmented crusted papules of 0.5-1.0 cm in size, distributed symmetrically over his entire back, extensor surface of bilateral forearm, arm, and bilateral dorsum of foot, interspersed with atrophic varioliform scarring (Figures 1 and 2). Routine laboratory workup was normal. Tuberculin (Mantoux) was strongly positive at 72 hours (23 × 23 mm) with central necrosis (Figure 3). Sputum for acid fast bacilli culture, chest radiograph, ultrasound abdomen, and pelvis did not reveal any abnormality. A biopsy specimen taken from a crusted papule over his forearm (Figure 4) showed fibrinoid necrosis, surrounded by mixed inflammatory infiltrate filling the entire dermis along with a few ill-defined epitheloid granulomas and lymphocytoclastic vasculitis. These are consistent with papulonecrotic tuberculid.The patient was started on a four drug combination therapy of rifampicin, isoniazid, pyrazinamide, and ethambutol for two months initially followed by a combination of rifampicin and isoniazid to complete a total of 6 months of standard antitubercular therapy. The patient responded well and all of the lesions eventually healed.

Dermatosis neglecta (DN) is a frequently underdiagnosed and under‐reported dermatological entity, which occurs due to unconscious neglect of self‐cleaning in individuals with some underlying physical or mental pathology. The lack of cleaning leads to accumulation of scales, dirt, sweat and sebum compacted together in the skin. Owing to its asymptomatic nature, diverse background and deceptive clinical presentation, DN is often missed or misdiagnosed by physicians. Awareness and recognition of this condition is essential to avoid unnecessary diagnostic and treatment procedures. The focus of this review article is to provide insights into this condition. We also intend to develop an algorithm for practical approach to a clinical diagnosis of dirt‐like dermatoses with reasonable accuracy. A few interesting cases of DN encountered in our institution are included in this article.

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Miliaria crystallina (MC) is an uncommon form of sweat retention syndrome that chiefly affects neonates. It is more common in hot and humid conditions, such as in tropical regions. It commonly presents as clusters of dewdrop-like vesicles on a non-erythematous base that heals with furfuraceous scaling. A clinical diagnosis is often sufficient. The differential diagnosis is wide and varying. One of the hallmarks of MC is its self-limiting nature. The purpose of this review is to increase awareness of this condition among physicians and dermatologists.

A 9-year-old girl from a low socioeconomic condition presented with severe itchy scalp for 6 months and oozy lesions over ears bilaterally for 3 weeks. Scalp examination showed innumerable nits, lice with scales, and serous crusts. She also had tender, erythematous, oozy, eczematous plaques, both over and behind the earlobes, associated with tender occipital lymphadenopathy. A few skin-colored papules were noted over the nape of neck (Figure 1). Rest of the physical examination was normal. Her hemogram showed iron deficiency anemia (Hb 7.0 g/dL). A clinical diagnosis of severe pediculosis capitis infestation with Id reaction and eczematous dermatitis was made. A louse was retrieved and viewed under the microscope (Figure 2, inset). She was given a course of 1% permethrin rinse (weekly once) for 2 weeks, two doses of ivermectin (6 mg 1 week apart), and topical steroids for the ear eczema. Four weeks later, she was symptom free. She was also educated on hygiene practices to avoid further infestation.Pediculosis capitis, caused by Pediculus humanus capitis, is most common in 3-to 12-year-old female children. 1,2 It is usually transmitted by close personal contact and through fomites. 2 The louse saliva antigen elicits an inflammatory response that causes pruritus and scratching, resulting in secondary impetignization. 2 Id reaction is an autosensitization dermatitis that manifests as itchy, erythematous, maculopapular/papulovesicular lesions distant from the primary inflammatory focus. The Id reaction secondary to pediculosis is called pediculid. 3 Florid pediculosis infestation can also lead to fever, malaise, cervical and occipital lymphadenopathy, iron deficiency anemia, and plica polonica. 4 Plica polonica is a compact mass of scalp hair with irreversibly entangled plaits stuck together with exudate and dirt. 5 The diagnosis is based on clinical features and the management of pediculosis is with topical 1% permethrin and oral ivermectin. Other treatment modalities include wet combing, 0.5% malathion, and newer drugs such as spinosad. The pediculid and eczema will eventually subside once pediculosis is treated. Sometimes it may require a short course combined topical antibiotic and steroid. 4 This case illustrates the importance to promptly diagnose and treat pediculosis capitis to prevent severe infestation and its sequelae.