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 Table of Contents  
CME ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 1-10

Cutaneous manifestations of physical and sexual child abuse


1 Pediatric Emergency Medicine, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
2 Dermatology, Henry Ford Hospital, Detroit, MI, USA

Date of Submission21-Jun-2019
Date of Acceptance03-Sep-2019
Date of Web Publication24-Dec-2019

Correspondence Address:
Dr Jennifer Noble
Division of Pediatric Emergency Medicine, Children's Hospital of Michigan, 3901 Beaubien St, Detroit, MI 48201
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_62_19

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  Abstract 


This article reviews cutaneous manifestations of physical and sexual abuse and a stepwise approach that dermatologists can apply to differentiate abusive from accidental injuries.

Keywords: Cutaneous manifestations, dermatology, pediatric physical abuse, pediatric sexual abuse


How to cite this article:
Noble J, Hartwig E, Shwayder T. Cutaneous manifestations of physical and sexual child abuse. Indian J Paediatr Dermatol 2020;21:1-10

How to cite this URL:
Noble J, Hartwig E, Shwayder T. Cutaneous manifestations of physical and sexual child abuse. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Jan 25];21:1-10. Available from: http://www.ijpd.in/text.asp?2020/21/1/1/273835




  Introduction Top


Over the past 50 years, the definition of child maltreatment has evolved from physical abuse alone to a broader definition that includes neglect, emotional, and sexual abuse. In the United States (US) in 1974, the federal Child Abuse Prevention and Treatment Act (CAPTA) was passed, requiring mandatory reporting of abuse in every state by personnel such as physicians and educators.[1] US statistics on child maltreatment have been collected since 1988 as a result of an amendment to CAPTA which established the National Child Abuse and Neglect Data System.

Each state in the US has its own definitions of child abuse and neglect that are based on standards set by federal law. Although figures vary yearly, approximately 700,000 cases of child abuse and neglect are reported annually in the US.[2] In 2016, there were an estimated 676,000 victims of child abuse and neglect in the US.[2] The greatest percentages of children suffered from neglect (74.8%), followed by physical abuse (18.2%) and sexual abuse (8.2%). There were 1,700 child fatalities as a consequence of maltreatment in the US during 2016.[2]

Recognizing child maltreatment early in its course is imperative as 30%–70% of abused children are at increased risk of subsequent injury.[3] Perpetrators of abuse may inflict more serious injuries or death unless there is early recognition and interventions are made.[3] In this review, we summarize various cutaneous findings of physical and sexual abuse in children as well as current evidence on management strategies.


  Part 1: Assessment Top


The most common form of child violence is physical abuse. The skin is the largest and most frequently involved organ, and bruises and burns are the most visible signs. Physicians are often the first professionals to observe and recognize the signs of intentional injury. Dermatologists, in particular, can help distinguish intentional injury from accidental or from skin diseases that mimic abuse.[4]

A history inconsistent with the physical findings is a hallmark of abuse.[5],[6] In assessing the plausibility of the history, it is important to keep in mind the developmental stage of the child as this can be used to corroborate or reject the history. Accidental injuries require certain motor skills and should be appropriate for the child's stage of development. Thus, a child who reportedly “fell down the stairs” should be old enough to be at least crawling. [Table 1] shows a list of red flags in history taking.
Table 1: Red flags in history taking

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Sentinel injuries are minor injuries with no plausible explanation in an infant that is not yet cruising and include bruises, intraoral injury, torn labia or sublingual frenulum, radial head subluxation, burn, or fracture.[7],[8] The recognition of such findings provides an opportunity for intervention and prevention of more serious consequences.[9]

Nonabusive injuries can mimic child maltreatment. Steps to avoid mistaking a nonabusive condition for abuse start with knowledge of the normal prepubertal and pubertal anatomy, understanding statistical associations with child abuse, and understanding mechanisms associated with nonabusive injuries. Finally, it is helpful to understand that most mimics will have injuries in the same organ system.


  Part 2: Physical Examination Indicating Physical Abuse Top


Cutaneous injuries are the single most common presentation of child physical abuse with up to 90% of victims presenting with skin findings.[4],[5],[10] Cutaneous manifestations of abuse include bruises, lacerations, abrasions, burns, oral trauma, bite marks, and traumatic alopecia. Often, the diagnosis of abuse cannot be made on the basis of the injury appearance in isolation. Taking a comprehensive history is crucial.

Bruises

A bruise or contusion is almost always from blunt force trauma. Some key factors in the history should include amount of force, location of the injury on the body, and contour and rigidity of object involved.

Common anatomic sites of nonaccidental bruising are shown in [Figure 1].
Figure 1: Common anatomic sites of nonaccidental bruising

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Studies have found that bruises are extremely rare in infants less than 6 months old, as they are not yet mobile. Thus, any single soft-tissue injury in a nonambulatory infant has a high correlation with abuse. With increasing age, there is a significant increase in accidental bruising with increases in mobility.[11],[12]

Bruising on the torso, ears, or neck (TEN) in a child <4 years old or any bruising in an infant 4 months old or less can be predictive of abuse.[13] This age-based TEN-4 clinical decision rule of pediatric bruising is helpful in the identification of potential child abuse by focusing on the body region [Figure 2] and [Figure 3].[13]
Figure 2: A 2-month-old child brought for evaluation of rash. The infant was being watched by the father who later admitted to “flicking” the child with his finger. Physical examination revealed multiple bruises and puncture wounds to the back consistent with physical abuse

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Figure 3: Young male with bruise to ear is highly suspicious for nonaccidental trauma

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Bruise distribution

Bruising is the most common physical sign of abuse, but it also is a frequent finding in an active child.[14],[15],[16] Accidental bruises commonly occur over any bony prominence, such as the forehead, hips, lower arms, spine, knees and anterior tibial area.[14],[15] Likelihood and number of bruises increase with increasing age and motor development. In the evaluation of bruising, consider the typical characteristics of bruising from everyday events in mobile and active children.

Bruises on the back of the body and trunk in all children and bruises in infants who are not independently mobile should raise suspicion for nonaccidental trauma.[17] Accidental bruising of the head and face is uncommon in nonambulatory infants as well as in school-aged children, but it is more common in toddlers, as they are not yet steady on their feet.[18]

Bruising of the genitalia and ears is highly suspicious for abuse as these areas are rarely injured accidentally.[8],[13] Similarly, bruising over relatively protected sites such as the upper arms, medial and posterior thighs, hands, and trunk are of concern for abuse. Abdominal bruising rarely occurs due to the flexibility and padding of the abdominal wall but when present is usually indicative of forceful grabbing or very forceful blunt impact. If abdominal bruising is noted on examination, the physician must also look for associated internal injury.[19]

Bruise patterns

The pattern of a bruise can reflect the shape of the object used to inflict it [Figure 4] and is a strong indicator of abuse. Loop marks are pathognomonic for abuse and result from striking the child with a doubled-over flexible cord such as an extension cord, rope, or belt. Linear bruises are produced by objects such as rods, switches, or wires. They are usually found over the buttocks, posterior legs, and back.[20] Any bruise with a distinct object shape should be considered suspicious for intentional injury. Larger bruises, clusters of bruises, or those associated with petechiae are also of concern for abuse [Figure 5] and [Figure 6].[17]
Figure 4: Patterns of bruises. Image reproduced with permission of Wiley

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Figure 5: A 14-month child evaluated for bruise marks on the buttock. Physical examination revealed linear bruises consistent with physical abuse with the strap from a belt

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Figure 6: A 13-year-old child in foster care who was whipped with an extension cord. Physical examination revealed multiple loop marks on thigh, buttocks, and arms

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Another pattern mark is seen in slap and grab injuries. Bruises in the shape of finger marks, often seen on the upper arm or trunk, indicate the child was grabbed forcefully [Figure 7]. When a child is slapped, blood is forced laterally by the pressure of the fingers, extravasating and leaving an outline of the fingers, while the actual point of impact appears normal. This phenomenon can be seen in any high-velocity injury, such as whippings, slaps, or being struck with a pole or rod. Spanking the child on the buttocks can also produce characteristic vertical bruises along the gluteal cleft secondary to the shearing damage to the vessels along the convex curvature of the buttocks.[19],[21]
Figure 7: A 2-year-old male child with bruises to the chest. Chest radiography revealed multiple rib fractures in addition to abdominal trauma

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Circumferential bruises or abrasions around wrists and ankles may suggest binding injuries. With prolonged time this may result in extreme ischemia and risk for gangrene [Figure 8]. This type of injury can also result in distal petechiae and edema. Edema alone may be seen if the ligature was “soft” and did not leave any mark or imprint. Similar marks can be seen at the oral commissure if the child has been gagged or around the neck after attempted strangulation [Figure 9]. Due to their location and shape, these marks are highly characteristic of abuse.
Figure 8: Young female with ligature marks at the ankle and dry gangrene of the feet consistent with physical abuse. Longstanding constriction may considerably impair blood flow and lead to ischemic changes

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Figure 9: An 8-year-old girl with multiple belt marks, bruises, and ligature mark around the neck consistent with physical abuse

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Petechiae

Petechiae are red, purple, or brown pinpoint hemorrhages (1–3 mm) in the skin believed to arise from rupture of venous capillaries. They may be caused by medical conditions or by elevated venous pressure from severe coughing, vomiting, temper tantrums, strangulation, or blunt force trauma.[22] Bruises associated with petechiae are much more common in abusive trauma.[17] Unexplained petechiae or bruising of the palate, specifically at the junction of the hard and soft palate, may be evidence of forced oral sex.[23] Petechiae over the head and neck not only may occur from diffuse blunt force trauma but also can occur from severe retching or coughing. This, however, has also been reported secondary to neck compression associated with strangulation or holding an infant's neck while shaking.[24]

Bite marks

All bite marks should raise suspicion of abuse and lead to full examination of the skin and abuse workup. A classic bite mark is circular or oval [Figure 10]. Human canine teeth leave the deepest and most prominent marks. The normal distance between the maxillary canine teeth in adults is 2.5–4.0 cm. Therefore, bites with an intercanine distance >3.0 cm were more likely to be inflicted by an adult. If the distance is <3 cm, the bite was probably caused by a child.[25]
Figure 10: A 6-month-old male child evaluated following a fall off of the changing table. The infant found to have bite marks to cheek and forearm. On further evaluation, he also had a femur fracture, rib fractures, and liver laceration

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As with any suspicious skin lesion, it is important to include a measurement standard in the photo so that an expert can consult on the images. Fresh bite marks can be swabbed for the presence of amylase and DNA from cellular material.[26] Using a photo, a forensic odontologist can also make impression models of the perpetrator's teeth and thus help identify the individual.[27] Carefully examine the penis in males, nipples in females, and digits (both fingers and toes) well for bites which sometimes are multiple in a parallel or a “ladder” distribution.

Animal bites are differentiated from human bites as they tend to tear the flesh and produce deeper lacerations/puncture wounds, whereas human bites compress the flesh and leave more superficial marks, with soft-tissue bruising.

Burns

Intentional burns are estimated to occur at a prevalence of 6%–40% in children who are physically abused.[28],[29],[30] There are several clues in the history that suggest nonaccidental burns [Table 2]. Burn abuse is more common in children under 3 years of age and is twice as common in boys compared with girls.[28],[31] There are several types of intentional burns found in children. Thermal scald burns are the most common, followed by contact and flame and then electrical and chemical burns. Up to 14% of scald injuries are due to abuse, and the great majority of intentional scalds (85%) are caused by tap water.[3],[28],[32],[33] Even small burns are quite painful and deserve urgent presentation to medical care for treatment.
Table 2: Red flags of nonaccidental burn history

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Children with nonaccidental scalds may have additional evidence of maltreatment, such as bruises, fractures, evidence of neglect, and a history of prior concerning injuries or burns.[34],[35],[36] Studies have shown that if there is a delay of >2 h in seeking medical care for scalds, the injury is more likely to be abusive.[32] A full head-to-toe examination in a child along with the past medical record review is essential.

Burn location

The location of a burn, though not pathognomonic, can be helpful when ruling out abuse. Face, dorsal hands, legs, feet, perineum, and buttocks tend to be predominant sites in abuse. The perineum and buttocks specifically are infrequently involved in accidental burns, and burns in this area are often inflicted as a punishment for toilet training accidents.[35],[37] This is consistent with the fact that forced immersions are frequent in the infant and toddler age groups.[38] In contrast, common locations for accidental burns include the head, neck, anterior trunk and arms, and reflecting areas likely to be involved in accidental hot liquid spills. Hand burns can be seen in accidents as well, but the more common site is the palm and palmar surface of the fingers, which would be in contact with the hot object, while the child is grasping it. When burns are due to abuse, it is the dorsum of the hand that is commonly involved, especially in contact burns.[37]

Burn patterns

Burn patterns are often caused by various household appliances, flame burns, cigarette burns, and electrical/chemical burns.[36],[37],[38] Forced immersion scald burns tend to be symmetrical and have clear lines of demarcation, often called tide marks.[3],[35],[36] They also tend to have uniform burn depth and commonly involve the buttocks, perineum, and extremities.[28]

Characteristic features of forced immersion include stocking and glove distribution, zebra stripes, and donut-hole sparing.[37],[39] Stocking and glove burns occur when a child's hands and/or feet are forcibly immersed in hot water, resulting in symmetrical, circumferential, and well-demarcated burns [Figure 11]. Zebra stripes are due to sparing of the flexural creases secondary to the body's flexed position in the hot liquid [Figure 12].[32],[35] Donut-hole sparing occurs when the child's buttocks are pressed against the bathtub which is relatively cooler than the water in it.[36]
Figure 11: A 17-month-old male child with burn to hand from intentional immersion injury. Note the well-demarcated border and lack of splash marks

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Figure 12: A 5-month-old female with zebra stripe burns from intentional immersion injury

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Both inflicted and accidental splash and spill burns have irregular margins and variable depth.[3] Distinguishing between accident and abuse in this type of a burn can be difficult as they both have irregular borders and nonuniform depth from movement away from the source.[36] They both are rarely full thickness as they typically involve shorter contact time.[40] They both have a characteristic appearance, in which the largest and deepest part of the burn is at the initial point of contact, usually head or chest, whereas the burn narrows and becomes more superficial as the liquid travels down the body and cools [Figure 13].[41],[42]
Figure 13: A 7-year-old male presented for evaluation of accidental scald burn from hot liquid which spilled on chest

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Splash and spill burns to the head, neck, and anterior trunk are commonly accidental with the explanation of the child pulling or spilling the hot liquid from a higher surface. Inflicted splash and spill burns are more frequently found on the buttocks and perineum, often from holding the child under a running faucet. Similarly, scald burns to buttocks, perineum or glove and stocking burns (hands and feet) are suspicious for physical abuse and warrant a thorough investigation.[29],[35],[36]

Certain burns have shapes suggestive of the objects used to inflict them. Accidental contact burns are often patchy and superficial as the child quickly withdraws from the hot object or the falling object brushes across the skin. They may or may not show a clear imprint, or the imprint may be asymmetric. Inflicted contact burns are deeper, sometimes multiple, and have more well-demarcated margins. They are commonly due to hot irons, radiators, hairdryers, curling irons, and stoves. Contact burns with uniform depth and well-demarcated margins located on typically protected areas of the body suggest abuse.[34]

Cigarette burns appear as 7 to 10 mm round, well-demarcated burns that have a deep central crater.[43] They often appear grouped on the face, hands, and feet.[29],[44] When accidental, they tend to be oval or eccentric and more superficial, as the child usually brushes against the cigarette.[29] Staphylococcal bullous impetigo is important in the differential diagnosis and often results in confusion. To diagnose cigarette burns, there should be an 8mm lesion with a deeper central burn or history provided by the child.[36]

Any cigarette burn to the eye without eyelid involvement should be considered abuse. Cigarette lighter burns are typically intentional since the time needed to inflict a visible skin burn is much longer than needed to light a cigarette.[45] Thus, there needs to be intent and preparation in order to inflict a visible cigarette lighter burn [Figure 14].
Figure 14: A 2-year-old male presented for evaluation of rash. The well-demarcated pattern burn on the back was an incidental finding with no explanation

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Other injuries

Inflicted bruises, abrasions, and burns can be found in the oral cavity.[23] Trauma to the lip can produce large, dome-shaped hematomas instead of macular ecchymoses.[26] Bruises or tears of the labial or lingual frenulum [Figure 15] can be a sign of a blow to the mouth, forced feeding, or forced oral sex.[23] A torn frenulum has been said to be diagnostic of abuse but can be seen when a child falls on his face.[46] The age and mobility level of the child must be considered. Other oral findings of abuse include burns or lacerations in the oral cavity and around the mouth (caused by hot food or utensils) and fractured or loose teeth. Significant tooth decay, especially after initial evaluation and assistance with establishing a “dental home,” suggests child neglect.
Figure 15: Bruising or tears of the frenulum are highly suspicious for nonaccidental trauma. They may be overlooked unless a comprehensive physical examination is performed

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  Part 3: Abusive Head Trauma Top


Abusive head trauma (formerly known as shaken baby syndrome) is inclusive of many mechanisms of injury including shaking, impact, hypoxic, and ischemic.[47] The incidence of abusive head trauma is estimated at 20–30 cases per 100,000 infants younger than 1 year of age.[48] Mild cases may go unrecognized or diagnosed with “colic,” [Figure 16] whereas fatal cases with additional injuries may be categorized as multiple traumatic injuries. The US data indicate a decline in abusive head trauma during the period from 2009 to 2014.[49]
Figure 16: Sentinel injuries such as minor bruises to the head should raise concern for nonaccidental trauma and a thorough workup should be done to rule out severe head injury

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Infants younger than 1 year have the highest incidence of abusive head trauma.[50] Risk factors include males younger than 6 months, medically complex infants, those on financial assistance, and those born to young mothers.[50],[51],[52],[53],[54] One-quarter of abusive head trauma is diagnosed in children older than 1 year.[55] Often, the history may be nonspecific such as a brief unexplained event that has resolved apnea, altered mental status, loss of consciousness, limpness, vomiting, seizure, poor feeding, or swelling of the scalp.[56] Studies have shown that often these infants had been previously seen by a provider who documented a sentinel injury such as bruising [Figure 16].[8],[13],[57],[58]

Associated cutaneous findings on physical examination may include frenular injuries or bruising with or without patterned marks. Individual fingertip grasp marks of the trunk or upper arms are particularly concerning for a shaking scenario [Figure 7]. In one study, 50% of infants younger than 6 months with suspicious bruising who underwent screening for occult injury were found to have at least one significant injury (abdominal, skeletal, or intracranial).[59]

The scalp may be boggy, a sign of a subgaleal hematoma due to tearing of small blood vessels and lifting of the scalp off the calvarium.[60] A bulging fontanel, sunsetting of the eyes, or large head circumference may be indicative of increased intracranial pressure or subdural hematoma.

Alopecia or scalp hematoma in a child can be traumatic in origin as seen when a parent pulls the child's hair or uses the hair to grab the child. Pulling of hair may lead to petechiae at the site of the pulled hair roots. Acute scalp tenderness may be present.[20] A similar picture of subgaleal hematoma may also be seen with repetitive tight braiding of the hair.


  Part 4: Physical Examination Indicating Sexual Abuse Top


Child sexual abuse is distinctly different in most circumstances from the acute sexual assault of an adolescent or adult patient. Child sexual abuse occurs when a minor is engaged in sexual activities that are developmentally inappropriate and for which the child is emotionally or physically unprepared.[61] Knowledge of the unique features of this type of maltreatment informs the approach to evaluation and management.[62] Childhood sexual abuse is more common in females (11%), and the perpetrator is more likely to be a person known rather than a stranger.[63]

In most cases, sexual abuse will be part of the chief complaint and not a finding that will be discovered accidentally. The exceptions to this may be a genital discharge, bleed, or new or unexplained “rash.” While a comprehensive forensic interview and examination is outside of the scope of the general clinician's role, a brief history and physical examination is essential. Gathering information concerning the event can be difficult, and the physical evidence for sexual abuse is often absent or unclear, making a definitive statement that abuse has occurred difficult to accomplish.

Physical evidence of sexual abuse

Clinicians should have a baseline understanding of female prepubertal and pubertal genital anatomy and be able to recognize and interpret any physical signs or laboratory results that may indicate abuse [Table 3].[64] Red genital mucosa is common and not a sign of abuse. History helps differentiate accidental from abusive injury in situations where there are lacerations or bruising in the genital region. The secondary findings that would augment physical findings include rashes, discharge, sexually transmitted infections (STIs), pregnancy, and the presence of semen. The physical examination, however, rarely is diagnostic. Typically, there are no signs of genital or anal injury following sexual abuse, especially when examined nonacutely.[65]
Table 3: Physical signs specific for sexual abuse

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Bruising

Although anogenital or penile bruising may be the result of sexual abuse from suction, biting, or excessive traction, it may not always indicate a sexual motive. Toileting accidents can be triggered for abusive genital injury. In sexual abuse, there may be petechial bruises, consistent with suction injury or hickeys on the skin. Oral bruising or petechia involving midline or bilateral palate at the junction of the hard and soft palate but not extending to involve tonsillar pillars, uvula, or posterior oropharynx may be secondary to oral-genital contact or assault with a blunt object.

Rashes and genital discharge

STIs that are highly diagnostic of abuse include gonorrhea, syphilis, condylomata, HIV, Chlamydia trachomatis, and Trichomonas vaginalis. Some of these are associated with classic skin findings and may have associated genital discharge [Figure 17], [Figure 18], [Figure 19], [Figure 20].[66] Skin findings associated with these STI may be secondary to nonabusive, vertical transmission. Condyloma accuminatum (anogenital warts) and herpes simplex are both caused by viruses which may lie dormant for a period of time and can easily be transmitted by fomites or fingers.[66] Mimics of sexual abuse such as lichen sclerosus, hymenal band, labial fusion, notches and clefts, and venous pooling around the rectum should be included in the differential. In children where there is a concern for STI, it is recommended to defer treatment until a definitive diagnosis has been obtained.[67]
Figure 17: An infant with mild genital discharge. Swab was positive for gonorrhea and chlamydia vaginitis

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Figure 18: Male infant with penile warts and no other signs of abuse

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Figure 19: A 20-month-old female child with vaginal warts and molluscum

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Figure 20: Condyloma young girl no other signs of abuse

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  Conclusion Top


When assessing for child physical abuse, consider the child's developmental capability and look for inconsistencies. Compare physical findings with patient history. Perform a complete physical examination, including intraoral, scalp, palms, soles, neck folds, and front and back of the ear. Remember that seemingly minor abusive injuries can precede severe physical abuse in infants. Oral injuries, particularly oral bleeding or a torn frenulum, may also be the predecessor of more severe trauma in infants. Historical features that increase suspicion for abuse include no history of injury, nonambulatory child, vaginal or hymenal trauma without a history of penetrating injury, extensive or severe trauma, presence of any trauma or history inconsistent with physical finding. All clinicians who suspect physical or sexual abuse are mandated reporters.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
Part 1: Assessment
Part 2: Physical...
Part 3: Abusive ...
Part 4: Physical...
Conclusion
References
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