A Case of Neurodermatitis Circumscipta of

Scalp Presenting as Patchy Alopecia

H Ambika, C Sujatha Vinod, and J Sushmita
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Abstract
Neurodermatitis or Lichen simplex chronicus (LSC) is chronic skin disease in which
emotional factors have a key role in the initiation of disease. A sixty year old lady presented
with itcy lesion of scalp with localised area of loss of hair. After proper history taking and
investigations she was diagnosed as LSC of scalp. She was treated with intralesional
steroids,oral doxepin and psychotherapy. Complete remission of symptoms with total
regrowth of hair occured in 3 months. The key role of emotional factors in causation of LSC
and a proper psychotherapy along with dermatological treatment is necessary for complete
cure of this condition.
Keywords: Neurodermatitis, scalp, patchy alopecia
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INTRODUCTION
Neurodermatitis circumscripta also commonly called as lichen simplex chronicus (LSC) is a
chronic skin disease characterized by lichenified plaques, which occur as result of constant
scratching or rubbing of skin. Itch sensation that provokes an intense desire to scratch or rub
a localized accessible area of skin is secondary to a psychological stress. Common sites are
nape of neck, ankles, anogenital region and scalp. Effective management of skin conditions
involves correction of the associated emotional factors.
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CASE REPORT

The present case report is about a 60-year-old female patient who presented to dermatology
out-patient department with itchy scalp lesion of 2 years duration. She also had complaints of
localized loss of hair in that area. There was no history of any local applications. There was
no history of any drug intake. On examination, there was a localized area of alopecia of 4 cm
4 cm size with underlying skin showing marked thickening to form a boggy swelling
[Figure 1] on the right parietoccipital region. There were no other skin lesions or hair and nail
changes. Systemic examination was within the normal limits. Provisional diagnosis of LSC of
scalp and tinea capitis was made. Woods lamp examination was negative and potassium
hydroxide mount did not reveal any fungal hyphae. Routine blood and urine investigations,
blood sugar, liver, renal and thyroid functions were normal. On further interrogation patients
bystanders gave a history that patient at times uses rock stones to rub scalp and may continue
rubbing until it bleeds. Skin biopsy revealed hyper keratosis hypergranulosis acanthosis
thickening of collagen in dermis suggesting LSC. Patient was given intralesional injection of

triamcinolone acetonide 2.5 mg/ml weekly for 4 weeks along with doxepin hydrochloride 10
mg at night. Patient was referred to Psychiatry Department for counseling. There was marked
reduction in itching in the 1st week and complete regrowth of hair at end of 4 weeks. Doxepin
was stopped after 3 months [Figures [Figures22 and and3].3]. Patient came for follow-up
monthly thereafter for 6 months with no relapse [Figure 4].

Figure 1
Boggy swelling with loss of hair
Figure 2
Partial growth after 2 months

Figure 3
Total regrowth after 3 months

Figure 4
After 6 months no recurrence
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DISCUSSION
Psychogenic factors play a key role in the initiation of pruritic sensation in LSC.[1] Itch
scratch cycle is paroxysmal and patient scratches until it pains or bleeding occurs. This selfperpetuating mechanism is the main pathogenesis of LSC.[2] Skin lesions are that of a
chronic eczema characterized by lichenified plaques. Most common sites are nape of neck,
ankle, scalp and anogenital region.[3] Emotional tension causes lichen simplex and in turn
patients with LSC in particular areas of the body (face, scalp, hands and genital area) are
more prone to psychological distress due to the appearance of lesions. Although not lifethreatening, it can produce an important psychosocial burden, sleep disturbance and sexual
dysfunction.[4] Overall dermatology life quality index was lower in one study in patients
with neurodermatitis than psoriasis.[5] Personality profiles of 60 patients with LSC were
compared to a normative sample of the normal Spanish population, who were free of any
kind of skin disease. Participants with LSC presented personality characteristics that differed
from the control group. The most significant variables were as follows: greater tendency to
pain-avoidance, greater dependency on other peoples desires and more conforming and
dutiful compared to the control group.[6] Effective management of skin conditions involves
simultaneous correction of psychological factors else recurrence is the rule.

Complications like secondary infection and occurrence of squamouscell carcinoma is also

reported in studies.[7] Topical treatment modalities for LSC with varying success are potent
topical steroids, intralesional steroids,[8] keratolytic agents such as salicylic acid, capsacin,
tacrolimus pimecrolimus and cryotherapy. Systemic modalities of treatment include sedative
antihistamines, tricyclic antidepressants and psychotherapy. Transcutaneous electric nerve
stimulation has been reported to be effective in reducing itch.[9] Botulinum toxin[10] and
topical doxepin cream are also reported useful.[11]
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Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
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REFERENCES
1. Chuh A, Wong W, Zawar V. The skin and the mind. Aust Fam Physician. 2006;35:7235.
[PubMed]
2. Agrawal SK, Khurana S. Lichen simplex. Indian Pediatr. 2005;42:388. [PubMed]
3. Rajalakshmi R, Thappa DM, Jaisankar TJ, Nath AK. Lichen simplex chronicus of
anogenital region: A clinico-etiological study. Indian J Dermatol Venereol Leprol.
2011;77:2836. [PubMed]
4. Ermertcan AT, Gencoglan G, Temeltas G, Horasan GD, Deveci A, Ozturk F. Sexual
dysfunction in female patients with neurodermatitis. J Androl. 2011;32:1659. [PubMed]
5. An JG, Liu YT, Xiao SX, Wang JM, Geng SM, Dong YY. Quality of life of patients with
neurodermatitis. Int J Med Sci. 2013;10:5938. [PMC free article] [PubMed]
6. Martn-Brufau R, Corbaln-Bern J, Ramirez-Andreo A, Brufau-Redondo C, LimianaGras R. Personality differences between patients with lichen simplex chronicus and normal
population: A study of pruritus. Eur J Dermatol. 2010;20:35963. [PubMed]
7. Wu M, Wang Y, Bu W, Jia G, Fang F, Zhao L. Squamous cell carcinoma arising in lichen
simplex chronicus. Eur J Dermatol. 2010;20:8589. [PubMed]
8. Vasistha LK, Singh G. Neurodermatitis and intralesional steroids. Dermatologica.
1978;157:1268. [PubMed]
9. Yksek J, Sezer E, Aksu M, Erkokmaz U. Transcutaneous electrical nerve stimulation for
reduction of pruritus in macular amyloidosis and lichen simplex. J Dermatol. 2011;38:546
52. [PubMed]
10. Messikh R, Atallah L, Aubin F, Humbert P. Botulinum toxin in disabling dermatological
diseases. Ann Dermatol Venereol. 2009;136(Suppl 4):S12936. [PubMed]
11. Thomson KF, Highet AS. 5% doxepin cream to treat persistent lichenification in a child.
Clin Exp Dermatol. 2001;26:100. [PubMed]
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A Case of Neurodermatitis Circumscipta of Scalp Presenting as Patchy Alopecia

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Review The skin and the mind.[Aust Fam Physician. 2006]

Lichen simplex.[Indian Pediatr. 2005]

Lichen simplex chronicus of anogenital region: a clinico-etiological study.[Indian J

Dermatol Venereol Leprol. 2011]

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Quality of life of patients with neurodermatitis.[Int J Med Sci. 2013]

Personality differences between patients with lichen simplex chronicus and normal
population: A study of pruritus.[Eur J Dermatol. 2010]

Squamous cell carcinoma arising in lichen simplex chronicus.[Eur J Dermatol. 2010]

Neurodermatitis and intralesional steroids.[Dermatologica. 1978]

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