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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 44-49

Terra firma-forme dermatosis: a hospital-based clinico-epidemiological study at a tertiary care centre in northern India

Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan, India

Date of Submission29-Mar-2019
Date of Decision28-Aug-2019
Date of Acceptance25-Feb-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Suresh Kumar Jain
MD Dermatologist, senior professor, Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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Background: Terra firma-forme dermatosis is an idiopathic keratinization disorder characterized by acquired, dirt-like plaques despite normal hygiene which was first described in 1987. Aims: We conducted a clinical study in patients who presented with Terra-firma forme dermatosis. In this we describe the clinical features of Terra firma-forme dermatosis along with a proposal of its diagnostic criteria. Methods: A prospective study was conducted at the dermatology department of a tertiary care hospital to identify cases of Terra firma-forme dermatosis diagnosed over a period of 14 months (July, 2016, to September, 2017). The diagnosis of Terra firma-forme dermatosis was confirmed in all patients who had com­plete resolution of each lesion after the application of 70% isopropyl alcohol. Results: Prevalence of Terra firma-forme dermatosis was 0.05% at our outpatient department. Male to female sex ratio was 4:1(37:9). 46 patients with Terra firma-forme dermatosis were identified, including 27 (58.6%) who presented with it as their primary concern. 36 (78.26 %) were from 6 to 18 years of age group. The mean duration of lesions was 6.86 months. The most common location was the neck. The commonest cause was ignorance regarding proper cleansing techniques, inadequate pressure while scrubbing the affected area. Limitations: A small sample size and relatively short duration of follow up. Conclusions: Terra-firma forme dermatosis is a benign dermatologic condition. Awareness among the clinicians about the existence of Terra firma-forme dermatosis is essential to save time for the clinician and to reduce the economic burden on the patient.

Keywords: Dermatosis neglecta, Duncan dermatosis, isopropyl alcohol

How to cite this article:
Kumar R, Singh A, Badyal R, Jain SK, Nyati A. Terra firma-forme dermatosis: a hospital-based clinico-epidemiological study at a tertiary care centre in northern India. Pigment Int 2020;7:44-9

How to cite this URL:
Kumar R, Singh A, Badyal R, Jain SK, Nyati A. Terra firma-forme dermatosis: a hospital-based clinico-epidemiological study at a tertiary care centre in northern India. Pigment Int [serial online] 2020 [cited 2022 Jun 27];7:44-9. Available from: https://www.pigmentinternational.com/text.asp?2020/7/1/44/289334

Key Messages: Terra-firma forme dermatosis is a common dermatosis which is often missed easily. Therefore, clinicians are need to be aware about the existence of Terra firma-forme dermatosis in order to save time, avoid unnecessary investigations and to reduce the economic burden and anxiety to the patient.

  Introduction Top

Terra-firma forme dermatosis (TFFD) is a clinical condition resembling dirt on the skin. In Latin the phrase terra-firma means dry land. [1],[2] Its first description was done by Duncan, Tschen and Knox in 1987. [3] The condition has been predominantly reported in children.[3],[4],[5],[6]

Dermatitis neglecta (DN), which is a somewhat related condition, was described by Poskitt and Wayte,[7] characterized by accumulation of hyperpigmented, hyperkeratotic, verrucous crusts secondary to poor skin hygiene.

The etiology, prevalence, age, gender and anatomic locations are still poorly defined. Although, it is not infrequent tobe recognized in clinical practice, TFFD has been described as an uncommon condition. This could be due to paucity of systematic studies and lack of significant epidemiological data on these patients. The absence of a standard definition and validated diagnostic criteria may have contributed to this underreporting. A need for correct and timely recognition exists. We describe the clinical features, diagnosis, course and treatment of a series of 46 patients with TFFD at our institute seen over a period of 14 months.

  Aims and objectives Top

We conducted a clinical study in patients who presented with TFFD. In the present study we describe the clinical features of TFFD along with a proposal of its diagnostic criteria.

  Methods Top

Written informed consent was obtained from the patients. A prospective study was conducted at the dermatology department of our tertiary care hospital to identify cases of TFFD diagnosed over a period of 14 months (July, 2016, to September, 2017). Collected variables included age, sex, anatomic location, duration, and comorbid conditions. Dermatitis neglecta cases were excluded if the history of hygiene in the area of lesions was uncertain. The diagnosis of TFFD was based on clinical presentation of asymptomatic brown to blackish areas with a velvety texture, not removable by washing with water and/or soaps (negative soap water swab test) but removed with gentle 70 % isopropyl alcohol swabbing (positive alcohol swab test). All patients in this study had normal washing habits. The demographic and clinical features of studied patients are summarized in [Table 1]. All patients were subjected to dermoscopic examination before and after alcohol swabbing.
Table 1 Demographic and clinical characteristics of46 TFFD patients in our study

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Statistical analysis

Clinical and dermoscopic findings are presented as absolute numbers (percentage).

  Results Top

Forty-six cases were identified. Thirty-seven (80.43%) were males and 9 (19.5%) females. Male to female sex ratio was around 4:1(37:9). Age ranged from 5 years to 70 years (mean 20.44 years). Twenty-seven (58.6%) patients presented with these lesions as their primary concern, whereas 6 (13.04%) presented with the lesions as secondary concerns. In the remaining 13 (28.26%) cases, the lesions were noticed on physical examination, and further history and evaluation confirmed TFFD. The most common lesion location was the neck in 18(39.1%) patients followed by lateral trunk in 9 (19.56%) cases [Table 1]. Less-common locations included the umbilicus and ear concha in 5 (10.8%) each, genitalia and chest in 4 (8.6%) each, ankles in three (6.5%) and areola and back in two (4.34%) cases each in conjunction with lesions on other sites. Almost all lesions were bilateral symmetrical. Classical dirt-like plaques were seen in 37 (80.43 %) patients while three (6.5 %) had reticulate; two (4.34 %) patients each had verrucous-like, stuck-on appearance and linear lesions respectively [Figure 1]. The mean duration of lesions before presentation was 6.86 months (range- 2 months to 24 months). The common co-morbid conditions associated were atopic dermatitis, keloid and leprosy in two patients each while vitiligo, discoid lupus erythematosus (DLE), leiomyoma, progressive macular hypomelanosis, genital ulcer, marginal keratoderma and tinea capitis in one patient each. All lesions readily cleared with gentle rubbing with alcohol swabs. One patient had recrudescence at umbilicus after 3 months. Moreover, no recurrences were seen in the patients who returned to the clinic for new concerns or follow-up of other conditions. The dermoscopic appearance of all studied patients revealed similar findings, with large polygonal plate-like brown scales arranged together giving a mosaic pattern or tile-like pattern interrupted in furrows. These features disappeared completely after alcohol swabbing of the lesions [Figure 2]e-f.
Figure 1 Various variants of TFFD. (a, b) classical reticulate type; (c, d) verrucous type; (e, f) stuck on type.

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Figure 2 Before and after cleaning image of TFFD. (a, b) isopropyl swab; (c, d) dermascopic finding; (e, f) using Dermlite DL3 dermatoscope (10 x magnification).

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  Discussion Top

TFFD is one of the dirt-like dermatoses[8] along with dermatitis neglecta (DN), confluent and reticulated papillomatosis (CRP), acanthosis nigricans (AN), and the “dirty neck syndrome” of atopic dermatitis.[9] TFFD and DN can be differentiated from dermatitis artefacta (DA) as here there is an element of not cleansing (act of omission) whereas there is a voluntary or involuntary act of creating an insult on the skin in the later (act of commission) [Table 2].[7]
Table 2 Differential diagnosis of TFFD[3],[7],[10],[11],[12],[13],[14],[15],[16]]

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Prolonged cell-to-cell adhesion is caused by delayed keratinocyte maturation which impairs the shedding process [3] while the excess of keratinocytes build-up with local sebum and dirt leads to the hyperpigmentation seen clinically.

Although, actual cause of TFFD is still not clear, the reported various causative factors emollients, sun exposure, failure to rinse the oil, or liquid cleansers during a shower, and application of urea-containing emollients on dry or eczematous skin may also be responsible. [17] We think the vigorous use of oils before and after baths could be one of the reasons for TFFD formation in our patients. There may be an association between TFFD and xerosis, which is also a disorder of keratinization.

Few case reports have mentioned genetic predisposition in this condition [1],[2],[5],[6] but none of findings were suggestive of genetic predisposition in our study. Although some patients had vitiligo, acne, keratoderma, and tinea, but the locations of the TFFD lesions were different from where these lesions and there was no relationship between these dermatoses and TFFD.

Previous case reports and studies have most commonly found lesions on skin folds. [1],[2],[5],[6] Similarly, we also found lesions on the flexures like, neck, trunk, umbilical fold, inguinal region and ankle in decreasing order.

Both sexes and all age groups have been found to be affected by TFFD though most common age group was in children.[1],[2],[5],[6] In our study, most of the patients were children and males. Most of our patients were boys and the lesions had been noticed by their mothers.

Recurrences were not reported in previous cases reports.[1],[2],[5],[6] We had similar findings and during a period of 14 months, only one case of recurrence was seen on umbilicus.

Although many small case series and case reports have been reported but still, only few studies of TFFD have been reported.[6],[18] From India, thirteen patients were reported.[19],[20],[21] In the two largest retrospective studies, Aslan et al.[18] reported 79 cases over 14 months period while Berk et al.[6] described 31 cases over 17 months duration, illustrating that the condition is not as uncommon as the literature might suggest. Large number of cases were reported from Turkey,[18] followed by USA. [1],[6],[22]

Our study revealed many important findings. Since there are no standard diagnostic criteria, the diagnosis of TFFD in most cases is clinical. Based on our experience of 46 cases, we have proposed a diagnostic criteria for TFFD [Table 3]. Cases were graded as definite, probable or possible TFFD based on these criteria. We applied the criteria on our cases and the diagnosis of TFFD was definite in 39 and probable in seven cases.
Table 3 Proposed diagnostic criteria for TFFD

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In a short period (46 cases in 14 months) a large number of cases suggests that TFFD may not be as uncommon as reported in the literature. Second, the large number of cases collected allows identification of the most common locations of lesions: neck, lateral trunk, umbilicus and ankle. Lastly, similar to other studies, our study also suggests that TFFD occurs more commonly in children 36 (78.26 %).

Similar to other previous studies, [23],[24] on dermoscopy, in all studied patients, we also found large polygonal plate-like brown scales arranged together giving a mosaic pattern or tile-like pattern interrupted in furrows, which were disappeared completely after alcohol swabbing of the lesions.

Timely diagnosis and treatment are necessary of TFFD. Isopropyl or 70% ethyl alcohol or “surgical spirit” swab is still the gold standard for diagnosis and treatment.[3],[14],[15],[16] Keratolytic agents such as lactic acid or 2% salicylic acid or urea lotion may be required in more resistant lesions and chronic lesions.[7],[12] In small children who do not tolerate alcohol due to the irritancy potential, freshly squeezed lemon juice is an ideal choice. [13],[17] Literature also has reports of successful treatment with scrub bath with pumice and oral retinoids.[2],[5],[6]

  Limitations of study Top

A small sample size and short duration of follow up has been a limitation in understanding the disease.

  Conclusion Top

TFFD is not probably uncommon than previously thought to be. The rapid clearance by scrubbing with surgical spirit gives an instant gratification and satisfaction for the patient, parents and the physician. In addition, to the best of our knowledge we are presenting the largest case series from India. We advocate more studies with histo-pathological correlation. Children and parents must be made aware by the clinicians about the benign nature of TFFD. The proposed diagnostic criteria may be used for making a diagnosis of TFFD and needs to be validated further in prospective studies and in different population groups.

Financial support and sponsorship


Conflicts of interestThere are no conflicts of interest

  References Top

Browning J, Rosen T. Terra firma forme dermatosis revisited. Dermatol Online J 2005;11:15.  Back to cited text no. 1
Guarneri C, Guarneri F, Cannav SP. Terra firma-forme dermatosis. Int J Dermatol 2008;47:482-4.  Back to cited text no. 2
Duncan WC, Tschen JA, Knox JM. Terra firma forme dermatosis. Arch Dermatol 1987;123:567-9.  Back to cited text no. 3
O’Brien TJ, Hall AP. Terra firmaforme dermatosis. Australas J Dermatol 1997;38:163-4.  Back to cited text no. 4
Akkash L, Badran D, Al-Omari AQ. Terra firma forme dermatosis. Case series and review of the literature. J Dtsch Dermatol Ges 2009;7:102-7.  Back to cited text no. 5
Berk DR. Firma-forme dermatosis: a retrospective review of 31 patients. Pediatr Dermatol 2012;29:297-300.  Back to cited text no. 6
Poskitt L, Wayte J. Dermatitis neglecta: unwashed dermatosis. Br J Dermatol 1995;132:827-39.  Back to cited text no. 7
Tan C. Dirt-adherent dermatosis: not worth an additional name. Arch Dermatol 2010;146:679-80  Back to cited text no. 8
Humphreys F, Spencer J, McLaren K et al. An histological and ultrastructural study of the ‘dirty neck’ appearance in atopic eczema. Clin Exp Dermatol 1996;21:17-9.  Back to cited text no. 9
Gougerot H, Carteaud A. Papillomatose pigmentée innominée [Unclassified pigmented papillomatosis]. Cas pour diagnostic. Bulletin de la Société française de dermatologie et de syphiligraphie. 1927;34:712-9  Back to cited text no. 10
Friedman SJ, Liles WJ. Cutis. Omphalokeratolith 1987;40:144-6.  Back to cited text no. 11
Hussein AAA. Clinical and pigmentary variation of pityriasis versicolor in Al-Muthana government’s patients. Med J Babylon 2014;7:383-8.  Back to cited text no. 12
Pollitzer S. Acanthosis nigricans. In: Unna PG, editor. International atlas of rare skin diseases. Part 4. London: HK Lewis and Co 1890. p. 63.  Back to cited text no. 13
Janovsky V. Acanthosis nigricans. In: Unna PG, editor. International atlas of rare skin diseases. Part 1. London: HK Lewis and Co 1890. p. 1.  Back to cited text no. 14
Palitz LL, Peck S. Amyloidosis cutis: a macular variant. AMA Arch Derm Syphilol 1952;65:451-7.  Back to cited text no. 15
Sharquie KE. Frictional dermal melanosis (Lifa Dis-ease) over bony prominences. Journal of the Faculty of Medicine, Baghdad, 1993;35:83-7.  Back to cited text no. 16
Erkek E, Sahin S, Cetin ED et al. Terra firma-forme dermatosis. Indian J Dermatol Venereol Leprol 2012;78:358-60.  Back to cited text no. 17
  [Full text]  
Aslan NC, Güler S, Demirci K, Isiyel E. Features of terra firma-forme dermatosis. Ann Fam Med 2018;16:52-54.  Back to cited text no. 18
Ashique KT, Kaliyadan F, Goyal T. Terra firma-forme dermatosis: report of a series of 11 cases and a brief review of the literature. Int J Dermatol 2016;55:769-74.  Back to cited text no. 19
Panchal K, Bhalla N, Salunke P, Jerajani H. Extensive terra firma forme dermatosis [TFFD]: A rare presentation. Indian Dermatol Online J 2015;6:458-9.  Back to cited text no. 20
[PUBMED]  [Full text]  
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Greywal T, Cohen PR. Terra firma-forme dermatosis: a report of ten individuals with Duncan’s dirty dermatosis and literature review. Dermatol Pract Concept 2015;5:29-33.  Back to cited text no. 22
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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