Special Interest Topics

Skin Manifestations of Abuse

Abuse takes many forms, including physical abuse, sexual abuse, emotional abuse and neglect. The definition of child abuse, by the Center for Prevention and Treatment of Child Abuse (USA), is stated as the mental and physical injury, sexual abuse, neglect or mistreatment of individuals under 18 years of age, perpetrated by a caregiver, which indicates that the health of the child is threatened (1). Physicians must always be alert for signs indicating any manifestation of abuse, looking for symptoms beyond skin lesions. The authors consider any form of abuse a medical emergency, recognizing that most children, or elderly, are unable to articulate their condition or alert authorities of any wrongdoing and rely nearly exclusively on the awareness of astute professionals. Many cases of abuse are left unrecognized by professionals, the findings being exceedingly subtle, often written off as innocuous lesions. Early recognition is crucial, not only to prevent subsequent injury which occurs in 30-70% of children, but reports have indicated that abuse tends to increase in severity with time (2), and early intervention may avert these avoidable events.
Advances in scientific analysis and medicine have allowed for objective evaluation and higher accuracy of garnering a correct diagnosis.
This chapter will primarily address the skin manifestations of child abuse, including common conditions that mimic lesions of abuse, and those brought on cultural practices that are oftentimes misdiagnosed as child abuse. It is equally important that a physician not wrongly accuse anyone of such a horrific crime as the repercussions of false accusations are grave; existing reports have included suicide of distraught parents mistakenly accused of abusing their child (3).
Reports of child abuse have been increasing significantly (4,5,6) and dermatologists are in a unique position to identify and prevent further abuse of children. The cutaneous signs of abuse, including bruises and burns, are the most frequent injury caused by physical abuse; all physicians, dermatologists especially, must remain vigilant in recognizing these signs despite little to no training or guidance. The challenge remains in distinguishing intentional from accidental injury, which occurs commonly in childhood, and recognizing even uncommon skin diseases that may mimic maltreatment. (7)
Approximately 48 States, and the District of Columbia, among other regions, designate professionals who are mandated by law to report child abuse and maltreatment. Physicians and other health-care workers are included, as they typically have frequent contact with children, most especially dermatologists, pediatricians, and emergency room physicians , and are the first professionals to observe and hopefully recognize the signs of intentional injury.

Demographics
According to Child Protective Services, more than 700,000 children were abused or neglected in 2009. In reality, these cases likely represent only a fraction of all cases of abuse (8). It is thought that many cases of abuse remain unreported, and abuse is rarely seen or acknowledged by individuals outside of the immediate family. Child maltreatment and abuse remains a concealed and hidden problem and despite the numbers of reported cases, some studies estimate that nearly 25% of U.S. children undergo some form of child abuse (9).
Although the short-term effects of physical abuse include lacerations, ecchymoses, burns and bone fractures, recent studies have found that the effects of abuse are long-lasting and include physical and emotional health problems. Cardiac and pulmonary disease in adulthood have been associated with childhood abuse (10,11); it is thought that prolonged mistreatment of children may lead to disruption of brain development and ultimately lead to dysfunctional immune and nervous systems (11).
Skin manifestations of abuse are the most visible of all injuries however other forms of abuse including neglect may also beget continuing damage. Emotional effects of maltreatment include anxiety, depression and the inability to form relationships with others. Studies have also shown that feeling of worthlessness continue into adulthood, causing some victims of abuse to consider or attempt suicide (12).

Workup
When initially facing a case of suspected abuse, the physician should approach the history like that of any other patient. Clues in the history that suggest abuse include an inconsistent or changing history with vague or absent details (13, 14). A delay by the caretaker in seeking help, frequently defined as waiting more than two hours before obtaining medical attention, without reasonable cause, or a child or patient who has repeated visits for the treatment of injuries is suspicious for abuse. Subtle signs by the child, such as overly passive or withdrawn behavior should also be noted by the physician and may be a strong indirect indication of abuse. The most common findings in the exam of a physically abused child include ecchymoses, burns (often cigarette burns), bites, lacerations, bites and traumatic alopecia (15); the common findings of maltreatment and how to recognize them will be reviewed here.

Ecchymoses
Ecchymoses and contusions, recognized clinically as subcutaneous purpura, are the most frequently seen signs of abuse (16, 17) (Figure 13.1), seen in about 80% of physical abuse cases (18). Interpreting these findings can be difficult, as most children are exceedingly physically active and will sustain multiple ecchmyoses from routine play. More than three ecchymoses, larger than 1.0 cm or of varying stages of evolution   signal possible signs of abuse (7). Contusions and ecchymoses on bony prominences, usual locations for accidental injury, such as the knees, forehead, anterior tibia, are common areas for non-violent trauma in ambulatory children. Areas of the body that are normally protected and not routinely affected during day-to-day physical play include the posterior and medial thighs, hands, ears, buttocks and genitals. The abdominal region is also rarely injured by accidental trauma, due to the protective layer of fat, and ecchymoses in this area require a large amount of force and may be accompanied by internal injury; these children should be examined fully and appropriate imaging and workup should be done to rule out internal organ damage (7). When signs of trauma are seen in usually protected areas, the physician should consider them suspicious for abuse and conduct a thorough history and physical.
Ecchymoses seen on non-ambulatory or pre-ambulatory children should be noted with great concern. Contusions are typically sustained during ambulatory movement by physically active children; young children without mobility and with any soft tissue ecchymoses or signs of trauma should be regarded as likely abused. This is in contrast to children who are beginning in their attempts to walk and may suffer multiple ecchymoses, often on their legs and forehead, with their unstable movements (7).
Examination of each ecchymosis and their shape may also offer clues as to their etiology; Ropes, belt straps, and buckles leave ecchymoses behind that reflect their form. These specific patterns and shapes are not typically seen with accidental trauma and are suspicious, and often confirmatory, for abuse (7). Spanking of children less than two years old is strongly discouraged by most experts in childcare, and has been associated with poor cognitive development in early childhood (19). Although spanking is legal, and common, in the United States, many European countries have outlawed the practice (19). Spanking will produce typical lesions on the skin, with parallel linear purpuric lesions and a small triangle at the base, corresponding to the interdigital space (7).
Objective measures have been developed to aid in the evaluation of ecchymoses. Using the fundamental pattern of color transformation undergone with time, bruises can be aged allowing differentiation between old and new lesions (20). The timeline for color change, from red to blue/purple then green/yellow, can be assessed by spectrophotometry to quantitatively determine age, and thus be used in the investigation of child abuse (20). The practice of using spectrophotometry to analyze and age bruises based on color change over time has not been introduced into routine clinical practice, but may play a significant role in social cases of child abuse.

Burns
Burns are the third most frequent cause of injury resulting in death in the pediatric population after car accidents and drowning (21).  They compromise about 5-22% of all physical abuse cases, most commonly in children younger than 3 years old (7).  The typical age of children most likely to experience burn abuse ranges from 22 to 40 months. (22). When gathering the history of injury, the child’s age and motor skills should be noted, and any discrepancy with the child’s physical limitations and the history should be considered suspicious for abuse.
A recent review of 258 injury cases was conducted to determine distinguishing characteristics between intentional and unintentional injuries based on best evidence. Maguire et al.  determined that the most common intentional scalds were immersion injuries and caused by hot tap water.  Areas most frequently affected were the extremities, and buttocks (Figure 13.2) and perineum, involved in 40-100% of cases, while only involved in less than 15% of accidental scalding cases (23) (22). Distinguishing features of these burns were their symmetry and clear margins; cases were frequently associated with current or previous fractures and other injuries (23). Forced immersion of a child in hot water will spare the folds and the resting point of the gluteal region. This type of abuse creates symmetric and accurate borders with uniform depth, while forced scalding of hands or feet will lead to “glove” or “sock” distribution burns. “Zebra stripes” and “doughnut hole” burns refer to two other presentations of abusive submersion in hot water. Forced submersion with flexed extremities will spare the flexural creases and create the striped “zebra” appearance (22). Pressing a child’s buttocks down along the cooler surface of a container of hot water spares the center giving the often-seen “doughnut hole” burn (22).  Intentional burns are usually found in multiplicity, and may be inflicted by hair curling or straightening irons, stoves, radiators, and commonly cigarettes. Cigarette burns, when intentional, are usually seen as multiple, often grouped, circular lesions of uniform size, typically 0.5 to 0.8 cm, with well-defined borders and a central crater; these lesions typically regress forming a scar (24). Accidental cigarette burns are more superficial, and oval in shape (Figure 13.3), as usually the child is able to quickly withdraw from the pain. Misdiagnosis of burns may occur with common mimickers, such as epidermolysis bullosa, impetigo, papular urticaria and contact dermatitis (25). Cigarette burns, especially when multiple, in various stages of healing, may be easily misdiagnosed as varicella or staphylococcal bullous impetigo. The authors have had experience with a case of suspected child abuse presenting as bullous lesions on the lower extremities of a young girl (Figure 13. 4). The suspicion that the lesions represented cigarette burns led to involvement of child protective services and the removal of the child from caretakers. This case emphasizes the utility of biopsy, which revealed a perivascular eosinophilic infiltrate in the superficial and deep dermis, consistent with bullous arthropod (blistering bug bites) and undermining any suspicions of abuse. We recommend close communication with the dermatopathologist reading these particularly sensitive cases allowing for more specific commenting on pertinent positives or negatives of tissue section. If available, these biopsies should be sent for rush evaluation
The features of intentional burn injury greatly contrast with those of unintentional injury, such as hot liquid spills, which are more likely to affect the head, neck and anterior trunk, and have irregular margins and varied depth (23). Any findings indicating abuse should be documented, with notation of location, size, and color, and a photograph taken as an objective record. It is also recommended that a skeletal survey be performed, due to the frequent association with additional injuries in 20-33% of cases (2, 26, 27). 

Sexual Abuse
Sexual abuse is defined as any sexual activity with a child below the age of legal consent Sexual activity may be vaginal, oral, rectal, and viewing or fondling of any sexual anatomy. The sheer volume of children being sexual abused, currently about 1% of all children yearly, makes this diagnosis one that the physician should always remain especially vigilant, as it has reached epidemic proportions. According to community surveys, prevalence of sexual abuse in children ranges from 6%-62% and 3%-16% in girls and boys, respectively.  It appears that cases of child abuse affect girls nearly 2.5 times more often than boys (28).
The most common offender of sexual abuse includes nonrelatives who are known to the child and family members (28). The physician must try to illicit a thorough history from the child in question. The victim is frequently truthful, and the confirmatory history by the child is commonly the gold standard in cases of abuse. Unfortunately, there are rarely dermatologic findings in sexual abuse.
The physical examination for a sexually abuse child includes signs of penetrating anogenital trauma such a hymenal injury, lacerations and bruising around the genitals, or scarring. Sexually transmitted disease in children outside the perinatal period is highly suspicious for sexual abuse. Children more than 3 years old who are diagnosed with Chlamydia trachomatis, Trichomonas vaginalis, syphilis, Neisseria gonorrhoeae, HIV, HPV infections and anogential warts or HSV should have a thorough investigation to rule out abuse as these findings are strongly diagnostic. It must be noted that Chlamydia trachomatis infection when acquired perinatally may be seen until the 2nd or 3rd year of life (29).
Genital warts are most commonly diagnosed by dermatologists, and children beyond the perinatal period with these findings should be evaluated carefully. Genital warts have been reported in children with history of sexual abuse, but it can also be seen in children without abuse, much like bacterial vaginosis, and is not sufficient to prove sexual abuse (30, 31); vertical transmission should be excluded. The verification of sexually transmitted genital warts is made more difficult by the long latency period before clinical presentation. Specific serotypes of HPV, including HPV-2 and HPV-3, are typically associated with cutaneous warts, but have also been reported to cause anogenital HPV lesions in children as well (32).  Both inappropriate contact via sexual abuse and innocuous transmission through casual contact may present similarly as genital warts. Currently, detection of HPV DNA is not standard practice; HPV is diagnosed through clinical identification or through biopsy of lesions. 
Physicians must be cautious with their accusations of abuse. Multiple normal congenital variations may mimic the findings of abuse. Before declarations of abuse are made against caretakers, variations and conditions including periurethral bands, perineal grooves, lichen sclerosis et atrophicus, lichen planus, Beçhets disease, perianal streptococcal dermatitis, and Kawasaki syndrome, among others, should be ruled out. Additional situational findings such as foreign body masturbation may also be mistaken for abuse. A child who is confirmed to have one sexually transmitted disease should undergo testing to look for additional diseases.

Additional Signs of Abuse
The oral cavity is an often overlooked aspect of the physical exam, but can identify many signs of abuse. Forced oral sex may cause petechiae or hematomas to form on the palate, specifically on the area of transition between the soft and hard palate. Signs of bruising, abrasions, or lip and lingual frenulum fissures can also be visualized in the mouth following aggressive forced feedings or forced oral sexual abuse. Clinical oral manifestations of HPV infection may also indicate signs of sexual abuse, but are difficult to support objectively. Condyloma acuminatum may be seen in the oral cavity, but HPV has also been correlated with other oral conditions, such as lichen planus, verrucous carcinoma, and pemphigus vulargis.  Oral HPV infection in healthy children has a prevalence varying from 12.3% to 48.1% (33). Due to the varying routes of transmission of HPV, the role of subtyping has not yet been clarified. Sexual intercourse or direct contact with infected mucosa and skin is the predominant route of infection, however perinatal transmission, breast milk, autoinoculation or heteroinocultion also remain other possible routes (33). Further signs of child abuse include tooth loss or fractures in the mouth. These signs may not only indicate physical abuse, but also abuse in the form of dental neglect. Neglect, usually chronic in nature, is defined by the failure of the caretaker to provide a child’s basic needs and provisions, including nutritional needs, clothing, education or healthcare. Chronic neglect may manifest dermatologically as scabies, pediculosis or as vitamin deficiencies. Hypovitaminosis A is seen most often in children aged 1-6 years; the role of vitamin A in maintaining epithelial integrity leads to many dermatologic signs of its deficiency. Children with hypovitaminosis A may present with generalized xerosis (dryness), often with scaling or fine wrinkling of the skin. Follicular hyperkeratosis, or phrynoderma, may be seen on thighs, arms or the bony prominences of the knees and elbows. Unlike other vitamin insufficiencies, vitamin D deficiency was not shown to be associated with the diagnosis of child abuse (34). Although vitamin D insufficiency may lead to fractures, the most common cause of multiple fractures in young children is nonaccidental trauma (34). A child with multiple fractures simultaneously, or one that is brought to the emergency room repeatedly for separate events of bone trauma highly suggests abuse.
Bites illustrate another method of physical injury, but are unique in that they can be objectively used to identify the abuser. Typical human bite marks are 2-5 cm oval, semi-circular or oval marks, occasionally with ecchymoses or with punctures caused by the canines; an intercanine distance less than 3.0 cm suggests a bite likely caused by a child, rather than an adult (35). Unlike animal bites that usually tear flesh, human bites are more likely to compress flesh and may be a source of disease transmission, mainly hepatitis (35).  Dental characteristics, or salivary DNA, may ultimately expose the abuser and have been used in court cases to match perpetrators to bite marks on victims (36). Forensic dentists may swab lesions for collection of DNA material, or make molds of the dental arch, and the physician should take accurate photographs of any suspected bites for documentation (35).
Traumatic or violent hair pulling, ultimately presenting as alopecia, petechiae or hematomas of the scalp, may be an additional sign of child abuse. The child will show signs of tenderness on palpation of affected areas of scalp. An extensive subgaleal hematoma was documented to occur following severe sheer stress from forceful hair pulling of a young child; this phenomenon is referred to as “scalping” due to the distinctive radiologic findings (37). Much like trichotillomania or traction alopecia, violent hair pulling of the scalp will show localized areas of hair loss with an irregular margin or outline; loose anagen syndrome, tinea capitis, and alopecia areata should be ruled out (7). Tinea capitis, or kerion, when active or resolving, may present as uneven and patchy hair loss (Figure 13.5).

Mistaken for Abuse:
Many clinical findings may mimic those of abuse, and these must be identified and distinguished early by physicians to prevent erroneously accusing caretakers and exposing them to unnecessary turmoil and possible prosecution. Several conditions ranging from congenital abnormalities to various cultural practices may present as clinical findings that are also similarly seen in cases of abuse.
Dermatologists often encounter mimickers of abuse, and can more readily identify these findings with accuracy. For physicians who only occasionally manage these somewhat rare dermatologic findings, the similarities between these conditions and those findings of abuse may lead to   incorrect conclusions.
Anal fissures may result from forced sexual abuse, and when seen in a child with significant behavior changes of sexualized behaviors, may raise concerns for sexual abuse. More commonly, however, the child will confirm history of constipation, or large bowl movements or hard stool, a more likely source of anal fissuring. Findings more specific for abuse include anal bruising, abrasions, and a history elicited by the child indicating sexual abuse.
Lichen sclerosus is a chronic inflammatory dermatosis that can present on young females and males and may mimic sexual abuse. Typically it presents as white papules, coalescing into plaques, with epidermal atrophy. Comedo-like plugs may be seen under dermoscopy which correspond to obliterated appendigeal ostia or follicular plugging, a feature also seen with discoid lupus or chronic cutaneous lupus (38). Vulvar lichen sclerosis may cause symptoms of pruritus, dysuria, even bleeding; penile lesions may present as new phimosis or urinary obstruction. Characteristic of lichen sclerosus is the figure-8 pattern, or butterfly lesions, typically on the perivaginal or perianal region, with sparing of the perineum between. Lesions found in the genital region may occasionally vesiculate secondary to excessive levels of inflammation, making trauma a understandable consideration for the examining physician. The lesions of lichen sclerosus evolve into smooth, shiny white plaques, and although they can resemble lesions of trauma or sexual abuse if found on the anogenital, or vulvar, region, the physician must consider alternate conditions and evaluate the patient closely. Lichen sclerosus may ultimately lead to obliteration and stenosis of the introitus, and represents an additional dermatologic emergency , requiring correct identification to prevent grave, irreversible results.
Skin biopsy, specifically punch or snip section, remains an additional tool for diagnosing equivocal cases of lichen sclerosus. The longest-standing lesion should be biopsied and evaluated by a dermatopathologist.
Congenital dermal melanocytosis, also referred to as mongolian spots, are blue-gray patches or macules seen on the lumbosacral or buttock area of infants, often observed at birth or within the first few weeks of life. Occasionally these lesions can be found in the perineal area and, if multiple, may be mistaken for bruises or a sign of sexual abuse (39, 40). The authors have also seen these blue-gray pigmented lesions on the face, one mimicking bruising around the eye of an infant (Figure 13.6). Features that help differentiate these benign lesions from those of abuse include the classical fixed homogeneous blue-gray color, unlike the variable spectrum of colors experienced by bruising and ecchymoses. These melanocytic lesions typically appear at birth, or within the first few weeks of life, and resolve by the fourth year of life, although occasionally will persist, more commonly in lesions found distal to the lumbosacral region. Histologic analysis of these lesions will show spindle-shaped melanocytes the lower levels of the dermis (41). Nevi, or birthmarks, may come in all shapes and sizes (Figure 13.7), but their even pigmentation and history of longstanding presence makes the diagnosis straightforward. 
Perianal streptococcal dermatitis represents another condition seen in children that can be misdiagnosed and misinterpreted as a sign of child abuse. It can be recognized as a well-demarcated brightly erythematous patch on perianal skin, and is caused by group A-beta hemolytic streptococci (Figure 13.5). Children between the ages of six months and ten years are commonly affected (42). The affected child often complains of pain, pruritus, and may experience blood-streaked stool. 
The literature contains multiple cases of suspected child abuse ultimately diagnosed as perianal streptococcal dermatitis, with a specific case involving skin beyond the perianal area and affecting penile skin (43, 44). The condition may also involve vulvar skin, and the physician should be reminded of this disorder when examining children with pain and erythema in the genital area which may be suspicious of sexual abuse (45).
Diagnosis is easily and quickly confirmed with a rapid streptococcal test, and a skin culture can be sent for alternative affirmation. Amoxicillin or penicillin remains first-line treatment.
The pediatric population is subject to many cultural practices not well understood by western physicians. Without knowledge of many of these practices, the impulse to misdiagnose the cutaneous findings as those of abuse may great, but physicians should be culturally aware and sensitive to these traditions.
The practice of “cupping” has been performed by a variety of cultures, including Middle-Eastern, Egyptian, Chinese, Greek and European, and these practices are slowly gaining popularity in western culture (46). Used for the treatment of various medical conditions, including polymyalgia rheumatica (46), cups of various shapes and sizes are placed on the skin and suction is created using low air pressure through heating of the cup or the air inside it. Lancing of the cup may allow the vacuum to draw blood into the cup, a practice known as “wet cupping”. Clinically, circular erythema, ecchymoses or hemorrhagic bullae may be seen, commonly on the back, shoulders or thorax. Frequently, these lesions are erroneously thought to be due signs of abuse leading to regrettable social and legal consequences for the family involved (47, 48, 49). 
Coin rubbing, also known as spooning or friction stroking, is a cultural practice seen in Chinese and Vietnamese cultures, and other Southeast Asian countries such as Cambodia and Laos (50). A smooth-edged surface, such as the back of a coin, is placed against lubricated or pre-oiled skin and pressed deep while being dragged down the muscles along acupuncture meridians (50); a symmetric, linear, “Christmas-tree” pattern on the back made up of linear ecchymotic or petechial streaks is commonly seen (50, 51). 
Children who are subjected to practices based on cultural beliefs may be reluctant to discuss these traditions with their healthcare providers. Embarrassment over cultural differences or shame in un-American practices may prevent full-disclosure when these lesions are noticed by the practitioner. Physicians should remain sensitive to ethnic differences and consider these customs and cultural rituals when confronted with unusual cutaneous lesions suspicious for abuse, and yet are not considered harmful to the children affected
When evaluating a patient for elder abuse, the same signs and findings as those with child abuse may be applied. Delay in seeking treatment, injuries in various stages of evolution, or injuries inconsistent with history are findings and observations strongly suspicious for abuse. Often signs of neglect, such as malnutrition, poor hygiene or decubitus ulcers are seen, and as most thorough exams require, the patient should be fully disrobed and evaluated in entirety. Although much of elder abuse lies beyond the scope of this chapter, the ubiquitous finding of multipharmacy in the geriatric population make overdosing or underdosing of their medication another form of abuse.

CONCLUSION 
Dermatologic emergencies are few in number, but represent significant clinical scenarios that require prompt attention and response by dermatologists and all health professionals.  The high frequency and incidence of child abuse worldwide necessitates a level of suspicion by physicians in identifying this true dermatologic emergency and taking necessary action. There is a moral, ethical, and legal obligation to report any strong suspicion or confirmation of child abuse to child protective services or to make a referral to a child advocacy center. All healthcare workers should be able to identify signs of abuse with the level of confidence required to potentially set into action the removal of a child from their family. Any tests, imaging or biopsies that may help in identifying lesions of abuse, or to rule out their presence, should be ordered and done quickly with results expedited.
The diagnosis of child abuse is a weighty one with severe and enduring consequences. With confirmation of abuse, and a systematic exclusion of any potential mimickers or dermatologic conditions, child protective services and the facility social worker should be alerted.
A missed diagnosis of child abuse may result in death of the child or continued violence and cruelty against the child. Scientific literature shows the statistically increased probability of behavioral, cognitive and psychological disorders that emerge in adulthood of those abuse in childhood, including depression, suicide, and addiction (52); these and other consequences can be minimized or avoided with a vigilant and conscientious physician, alert to signs of abuse. However, the physician must always bear in mind that an erroneous charge of child abuse may cause undue anguish and distress and possible loss of reputation to the individual charged with simultaneous legal ramifications, and ultimately may lead to unnecessary separation of a child from their home and family.


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