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 Table of Contents  
Year : 2018  |  Volume : 19  |  Issue : 3  |  Page : 187-193

Skin lesions simulating child abuse

1 Department of Pediatric Dermatology, Indira Ghandi Institute of Child Health, Bengaluru, Karnataka, India
2 Birmingham Women's and Children's Hospital NHS Foundation trust; Department of Dermatology, University of Birmingham, Birmingham, UK

Date of Web Publication28-Jun-2018

Correspondence Address:
Dr. Sahana M Srinivas
Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_56_18

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Child abuse is a broad term which describes various forms of maltreatment and neglect in children and is recognized increasingly. Physical abuse presents to dermatologists as well as pediatricians because the skin is so readily accessible for harm. Doctors unfamiliar with the wide range of skin disorders that simulate child abuse may mistakenly diagnose child abuse or “fabricated or induced illness by carers” (Munchausen by proxy), with traumatic consequences for the family. Mimics of child abuse include various cultural practices, birthmarks, bleeding disorders, bacterial infections, bullous diseases, and hereditary conditions. Dermatitis artefacta and self-harm must also be considered. Observation of the skin lesions and their evolution during hospitalization may provide the correct answer, but knowledge of the morphology and presentation of various skin disorders is crucial to avoid incorrect diagnosis of child abuse. This article describes some of the less well-known mimics of child abuse. It is essential that dermatologists support pediatricians in managing conditions that appear unusual and possibly artifactual.

Keywords: Child, physical abuse, sexual abuse, simulating, skin disorder

How to cite this article:
Srinivas SM, Moss C. Skin lesions simulating child abuse. Indian J Paediatr Dermatol 2018;19:187-93

How to cite this URL:
Srinivas SM, Moss C. Skin lesions simulating child abuse. Indian J Paediatr Dermatol [serial online] 2018 [cited 2020 Oct 21];19:187-93. Available from: https://www.ijpd.in/text.asp?2018/19/3/187/235494

  Introduction Top

The World Health Organization (WHO) defines the four main types of child abuse and maltreatment as physical abuse, sexual abuse, emotional abuse, and neglect.[1] Dermatologists have a particular role in detecting physical abuse because cutaneous manifestations are the most common presenting signs. Furthermore, the carer perpetrating these injuries may state that the child has a skin disease, a claim which a pediatrician may not feel competent to refute. Conversely, a child with a genuine skin disease may be suspected, by doctors unfamiliar with the manifestations of that particular condition, to be the victim of child abuse, with serious consequences for the whole family.[2] Dermatologists have an important role here as 90% of cutaneous mimics can be differentiated from intentional and accidental injury by a thorough history, physical and cutaneous examination along with laboratory investigations.[3] The differential diagnosis of child physical abuse is outlined in [Table 1].
Table 1: Dermatological differential diagnosis of skin lesions of child physical abuse

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Dermatological mimics of child sexual abuse are more of a problem for pediatricians than for dermatologists. Pediatricians may be unfamiliar with the skin disorders, well known to dermatologists, which can affect the genital and perianal regions. However, dermatologists should not be complacent: the presence of mimics does not necessarily exclude child abuse. For example, lichen sclerosus et atrophicus, which is probably an autoimmune disorder, is said to be more common in girls who have been sexually abused, perhaps as a Koebner effect. The differential diagnosis of child sexual abuse is outlined in [Table 2] but not further discussed here.
Table 2: Dermatological differential diagnosis of skin lesions of child sexual abuse

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There is, not surprisingly, very little literature regarding the incidence of misdiagnosis of dermatological disease as abuse. In a prospective, observational, cross-sectional study of 2890 children under 10 years, undergoing evaluation for physical abuse by suitably trained pediatricians, 137 children had at least one feature simulating abuse and in 69 children this involved the skin. Twenty-eight percent had birthmarks (mongolian spots, hemangioma, and port-wine stain), 10% had coagulopathies (idiopathic thrombocytopenic purpura, Fanconi anemia, infectious bone marrow suppression, and von Willebrand's disease type 1), 22% had dermatological conditions (contact dermatitis, postinflammatory hyperpigmentation, phytodermatitis, atopic dermatitis, urticaria pigmentosa, urticaria, and anaphylaxis), 20% had infection (cellulitis, erysipelas, impetigo, staphylococcal scalded skin syndrome, tinea capitis, tinea corporis, herpes simplex virus encephalitis), and 19% had miscellaneous conditions (clothing and hair dye, child bite, and Henoch–Schonlein purpura).[4]

Most of the conditions that can simulate child physical abuse in children are well known to dermatologists. In this article, we describe a selection of those with which dermatologists may be less familiar.

  Cultural Practices and Complementary Medical Treatments That Damage the Skin Top

Different cultures and alternative systems of medicine employ a variety of techniques intended as therapy but which damage the skin. These include coining/spooning, cupping, moxibustion, branding, and salting.[3] These practices are not intentionally abusive, but may mimic abuse, and in children, who have not willingly submitted to the treatment, could actually be considered abusive.

Coining, also called spooning, coin rubbing or Cao gio, is practiced in Vietnam and some areas of South East Asia as a remedy for fever, headache, vomiting, and seizures. It involves applying heated mentholated oil on the back and shoulders and then rubbing with a coin, producing ecchymosis or linear petechiae. Spooning is a similar technique practiced in China using a porcelain spoon.[5]

Cupping is practiced in the United States, Latin America, and Eastern Europe for many symptoms including fever, pain, and poor appetite. A glass cup is heated and applied to the skin to create a vacuum, resulting in circular petechiae or suction bruises [Figure 7].[6] Moxibustion is mainly used in Asian cultures for conditions such as enuresis, behavioral disorders, and asthma. Moxa herb (Artemisia vulgaris) is rolled into a stick, ignited, and used to heat the affected body part, resulting in circular erythema or burns.[7] Branding is a traditional remedy still practiced in India for fever, irritability, and convulsions. A symbolic mark (third-degree burn) is created on the skin using a hot iron rod, hot glass bangle, or agarbatti (incense stick) on any part of the body but usually around the umbilicus [Figure 8].[8]
Figure 1: Bullous impetigo lesions resembling burns

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Figure 2: Erosion on the heel in epidermolysis bullosa mimicking scald injury

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Figure 3: Infantile hemangioma around the periocular region resembling a traumatic hematoma

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Figure 4: Multiple purplish bruise-like nodules on the shinsin erythema nodosum

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Figure 5: Bruise-like lesions of lichen aureuson the lower back

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Figure 6: Lichen scleroses et atrophicus scarring mimicking child abuse

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Figure 7: Ecchymotic plaque on the neck due to cupping

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Figure 8: Branding marks on the nape of neck

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These procedures are all painful and unlikely to confer any benefit other than as a counter irritant. Their use in non consenting infants and children should be discouraged. Dermatologists must be aware of these practices to elicit the correct history and counsel parents accordingly.

  Coagulation Disorders Top

Both congenital and acquired coagulation disorders can present with excessive bruising which may be mistaken for child abuse [Table 1]. A family history of a coagulation defect such as hemophilia or von Willebrand's disease is obviously helpful. There may be further clues on examination. Bruising due to coagulation disorders has a configuration and distribution consistent with injury, but the bruises are disproportionately severe [Figure 9].[3] Accidental bruises rarely occur on the buttocks in an infant or child wearing a diaper. Common patterns of accidental bruising in children have been documented.[9] Bruises accompanied by petechiae and oral ulcers can differentiate immune thrombocytopenic purpura from child abuse [Figure 10] and [Figure 11].[10] Vitamin C deficiency causes perifollicular petechiae. Vitamin K deficiency may present with ecchymotic nodules which persist for several days. A thorough history and examination will usually identify these conditions, but all children with persistent easy or excessive bruising should be investigated for a coagulation defect.
Figure 9: Bruising in hemophilia

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Figure 10: Ecchymosis along with petechiae in immune thrombocytopenic purpura

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Figure 11: Oral ulcers in the same child of Figure 4

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  Malignancies Top

Neuroblastoma is a rare childhood malignancy of the peripheral sympathetic nervous system and presents with a mass in the chest or abdomen, abdominal pain, fever, fatigue, bone pain, subcutaneous nodules, periorbital ecchymosis, and proptosis. Periorbital ecchymosis without the other features is easily mistaken for child abuse.[11] Leukemia can present with the bluish lumps of extramedullary hemopoiesis resembling bruises or with thrombocytopenia, manifesting as petechiae and ecchymosis. A complete history, thorough examination, and investigation can differentiate these conditions from child abuse.

  Genetic Disorders of Bone and Connective Tissue Top

Ehlers–Danlos syndrome is a group of rare inherited connective tissue disorders characterized by hyperextensibility of skin and joints, manifesting as skin fragility, recurrent joint dislocation, easy bruising and gaping, or cigarette-paper scars [Figure 12] and [Figure 13]. These features, representing abnormal responses to physical trauma, may be interpreted incorrectly as child abuse.[12] Likewise, osteogenesis imperfecta is frequently confused with abuse and neglect. It is an inherited disorder of bony fragility with easy bruising, bone fractures, and atrophic scars. The pattern of skin lesions along with the presence of blue sclerae, hearing impairment, osteopenia, or a positive family history help to differentiate these conditions from child abuse.[13] However, accurate diagnosis may require genetic testing which is not easily available. Those engaging in medicolegal practice will be aware that these diagnoses are sometimes suggested by lawyers defending alleged perpetrators of child abuse.
Figure 12: Multiple scarring on the lower legs in Ehlers–Danlos syndrome

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Figure 13: Cigarette-paper scarring on the knee joint in Ehlers–Danlos syndrome

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  Growth Striae Top

Horizontal growth striae are a normal finding across the back and thighs in many healthy adolescents. Mature striae are skin colored, but initially they may be strikingly red or pink, resembling whiplash marks [Figure 14]. However, the distribution, age of onset, and history of a recent growth spurt are characteristic and no investigations are required to establish this dermatological diagnosis.
Figure 14: Growth striae mimicking whiplash injuries

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  Degos Disease Top

Degos disease is a rare and sometimes fatal obliterative vasculopathy of unknown cause, characterized by multiple infarcts in skin and viscera. The condition usually presents with characteristic skin lesions: round, 3–10 mm diameter scar-like lesions with a pink rim and atrophic, porcelain-white center. The skin is affected in one-third of cases and the most common cause of death is bowel infarction and perforation. Pediatric degos disease is extremely rare and has been recognized only recently as a simulator of nonaccidental injury in infants.[14],[15] The skin lesions can be mistaken for healing cigarette burns. More significantly, there may be subdural effusion, indistinguishable on imaging from subdural hemorrhage, and in infants inevitably misdiagnosed as child abuse. The prognosis is poor as further neurological features develop including progressive cranial nerve palsies and stroke. Histology of affected tissue shows the characteristic wedge-shaped infarcts. There may also be demyelination of the optic nerve, retinal artery thrombosis, and cataract. Degos disease, although rare, must be considered in the differential diagnosis of subdural fluid and unusual skin lesions in cases of suspected child abuse.[14]

  Congenital Insensitivity to Pain Top

The term congenital insensitivity to pain is also used for the hereditary sensory and autonomic neuropathies, all of which are characterized by reduced pain perception. Several genes are known to be responsible for the different subtypes, some of which are autosomal dominant and some recessive. Clinical features include self-mutilating injuries of the fingers and tongue, as well as widespread scars and deformities, with multiple fractures and joint damage, secondary to impaired sensation.[16] Additional neurological features such as anhidrosis and mental retardation help to differentiate these conditions from child abuse. However, as mentioned above, physical abuse may coexist, as children and adults with learning disability are especially vulnerable.

  Mid-Face Toddler Excoriation Syndrome Top

Mid-face toddler excoriation syndrome (MiTES) is a condition recently described by the authors and characterized by chronic, habitual, intense scratching, and pulling of the skin in the mid-face region, especially around the nose, forehead, and eyes.[17] It starts during infancy, sometimes within the first year, and presents with recurrent erosions, ulcers, and deep scars in the mid-face region [Figure 15]. It improves with time, and teenagers may describe an unbearable urge to scratch which they have learned to resist. There may be associated neurological deficit but evidence of insensitivity to pain is usually otherwise absent. However, in some cases, biallelic mutations in pain insensitivity genes have been found. This unusual pattern of injuries with scarring is easily mistaken for child abuse or fabricated and induced illness because it is hard to believe the parents' assertion that the child is responsible for such severe and persistent damage.
Figure 15: Case of mid-face toddler excoriation syndrome showing multiple erosions and scarring on the mid face

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  Phytophotodermatitis Top

Phytophotodermatitis, although rarely reported in children, may be misdiagnosed as burns or lash marks. Erythema, vesicles, and later hyperpigmentation occur in bizarre patterns, usually with streaks or even resembling the shape of a hand.[18] A history of preceding inflammation without the successive color changes of a bruise helps to differentiate this from abuse. There may be a history of playing in an area where suspect plants grow: it may be necessary to question the child away from parents in case they have trespassed out of bounds.

  Accidental Laxative Ingestion Top

Laxatives may look and even taste like chocolate, leading to inadvertent ingestion by an inquisitive child. Excessive ingestion of a laxative which contains an anthraquinone such as senna, in a child wearing diapers, results in pooling of diarrheal stool containing the irritant drug. A characteristic diamond-shaped pattern of erythema and blistering has been described on the buttocks, linear borders corresponding to the diaper edge, and sparing of the perianal area and gluteal cleft consistent with an irritant contact dermatitis.[19] This may be followed by the brown staining well known to dermatologists as a topical effect of anthralin. However, the pattern varies according to the mobility of the child and length of exposure, and the gluteal cleft may be affected. In the absence of a history of laxative ingestion, localization to the diaper area, as well as a history of profuse, loose, red-brown stool help to differentiate this presentation from an immersion burn or scald.

  Dermatitis Artefacta Top

Dermatologists usually recognize dermatitis artefacta from the bizarre shapes of lesions which completely differ from patterns seen in skin disease and from its occurrence only on accessible parts of the body.[20] Pediatricians faced with such lesions are more prone to attribute the damage to abuse than to consider that it might be self-inflicted. Again, it is important to recognize that the two conditions can coexist, and self-harm or dermatitis artefacta is sometimes a “cry for help” in a child trapped in an abusive situation. Sensitive questioning and collaboration are important to ensure a balanced opinion and correct diagnosis.

  Conclusions Top

The consequences of misdiagnosing disease as child abuse are serious. Paediatricians and dermatologists must work together to differentiate child abuse from dermatological disease. We should all keep this differential diagnosis in mind when faced with unusual or apparently artifactual lesions in children. A thorough history, examination, and investigations can differentiate dermatological disorders that can be misdiagnosed as abuse.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. World Report on Violence and Health. Child Abuse and Neglect by Parents and other Caregivers. Ch. 3. Available from: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap3.pdf. [Last accessed on 2018 May 06].  Back to cited text no. 1
Bilo BA, Oranje AP, Shwayder T, Hobbs CJ. Dermatological disorders and artefacts. In: Cutaneous Manifestations of Child Abuse and their Differential Diagnosis: Blunt Force Trauma. Berlin: Springer; 2012.  Back to cited text no. 2
Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol 2006;23:311-20.  Back to cited text no. 3
Schwartz KA, Metz J, Feldman K, Sidbury R, Lindberg DM; the ExSTRA Investigators. Cutaneous findings mistaken for physical abuse: Present but not pervasive. Pediatr Dermatol 2014;31:146-55.  Back to cited text no. 4
Yeatman GW, Shaw C, Barlow MJ, Barlett G. Pseudobattering in Vietnamese children. Pediatrics 1976;58:616-8.  Back to cited text no. 5
Asnes RS, Wisotsky DH. Cupping lesions simulating child abuse. J Pediatr 1981;99:267-8.  Back to cited text no. 6
Reinhart MA, Ruhs H. Moxibustion. Clin Pediatr 1985;24:58-9.  Back to cited text no. 7
Kumar S, Rashmi S. Branding: A harmful practice. Indian Pediatr 2005;42:721.  Back to cited text no. 8
Collins PW, Hamilton M, Dunstan FD, Maguire S, Nuttall DE, Liesner R, et al. Patterns of bruising in preschool children with inherited bleeding disorders: A longitudinal study. Arch Dis Child 2017;102:1110-7.  Back to cited text no. 9
Coulter K. Bruising in children. Curr Paediatr 1995;5:225-9.  Back to cited text no. 10
Park KU, Prahlow JA. Sudden death due to adrenal neuroblastoma: Child abuse mimic? Forensic Sci Med Pathol 2011;7:47-52.  Back to cited text no. 11
Castori M. Ehlers-Danlos syndrome(s) mimicking child abuse: Is there an impact on clinical practice? Am J Med Genet C Semin Med Genet 2015;169:289-92.  Back to cited text no. 12
Pandya NK, Baldwin K, Kamath AF, Wenger DR, Hosalkar HS. Unexplained fractures: Child abuse or bone disease? A systematic review. Clin Orthop Relat Res 2011;469:805-12.  Back to cited text no. 13
Moss C, Wassmer E, Debelle G, Hackett S, Goodyear H, Malcomson R, et al. Degos disease: A new simulator of non-accidental injury. Dev Med Child Neurol 2009;51:647-50.  Back to cited text no. 14
Karaoglu P, Topçu Y, Bayram E, Yis U, Akarsu S, Atalay E, et al. Severe neurologic involvement of Degos disease in a pediatric patient. J Child Neurol 2014;29:550-4.  Back to cited text no. 15
Van den Bosch GE, Baartmans MG, Vos P, Dokter J, White T, Tibloel D. Pain insensitivity syndrome misinterpreted as inflicting burns. Pediatrics 2014;133:e1381-7.  Back to cited text no. 16
Srinivas SM, Gowda VK, Owen CM, Moss C, Hiremagalore R. Mid-face toddler excoriation syndrome (MiTES): A new paediatric diagnosis. Clin Exp Dermatol 2017;42:68-71.  Back to cited text no. 17
Coffman K, Boyce WT, Hansen RC. Phytophotodermatitis simulating child abuse. Am J Dis Child 1985;139:239-40.  Back to cited text no. 18
Leventhal JM, Griffin D, Duncan KO, Starling S, Christian CW, Kutz T. Laxative-induced dermatitis of the buttocks incorrectly suspected to be abusive burns. Pediatrics 2001;107:178-9.  Back to cited text no. 19
Moss C. Dermatitis artefacta in children and adolescents. Paediatr Child Health 2015;25:84-9.  Back to cited text no. 20


  [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]

  [Table 1], [Table 2]


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