Cutaneous mimickers of physical child abuse: A brief overview

Abstract

Child abuse is one of the medico-legal issues a physician may face during his/her clinical practice. It has devastating effects on both the child and family, especially psychological. If falsely identified as a child abuse case, it could result in detrimental consequences. Therefore, physicians must recognise and be able to rule out child abuse mimickers, which are often conditions that are mistakenly confused with true physical child abuse. Injuries like bruises and burns are common presentations and therefore it is important to consider cutaneous abuse mimics to avoid incorrect diagnosis of child abuse. This review article sheds light on the most common cutaneous conditions that can mimic physical child abuse, where patients present with patterns of various skin lesions that raise a suspicion of child abuse.

Keywords

Child abuse physical abuse mimickers cutaneous abuse mimics incorrect diagnosis cutaneous lesions clinical forensic medicine

Introduction

The Child Abuse Prevention and Treatment Act in the US defines child abuse as “the action that leads to significant physical or emotional harm, possibility of immediate harm, sexual abuse, or death to the child by the individual often responsible for the child’s safety and protection, such as the parent or caregiver”.¹ The main forms of child abuse are physical abuse, sexual abuse, emotional abuse and neglect.²

Child abuse is one of the medico-legal issues a physician may face during his/her clinical practice. It has several devastating effects: in cases of true child abuse, it could result in complete separation of the child from his/her parents. On the other hand, if the case is falsely identified as a child abuse case, it could lead to temporary isolation of the child from his/her parents leading to unnecessary frustration, anxiety and loss of patient–physician synergy. It is, therefore, very important for physicians to recognise and be able to rule out child abuse mimickers, which are conditions that are mistakenly confused with physical child abuse.³

Physical abuse is the second most common form of child abuse following child neglect.⁴ Forms of physical abuse primarily include cutaneous injury, fractures and head trauma. Injuries like bruises and burns are common presentations of physical child abuse and therefore it is important to consider cutaneous abuse mimics to avoid incorrect diagnosis. A study that evaluated suspected cases of child abuse reported that cutaneous mimickers were found in about 50% of the cases with mimickers of child abuse.⁵ This review article focuses on the most common cutaneous conditions that can mimic physical child abuse, where patients present with patterns of various skin lesions that raise a suspicion of child abuse. Several reported cases that were initially and erroneously diagnosed as child abuse, but later on found to be due to medical conditions that mimicked the presentation of child abuse, are reviewed.

Cutaneous mimickers of physical child abuse

Recognising inflicted cutaneous injuries and distinguishing them from other conditions that may mimic child abuse is a crucial skill that every physician should attain. One of the most common presentations of physical abuse in children is the presence of cutaneous lesions.⁶ Cutaneous mimickers of physical child abuse could be primarily classified based on the clinical presentation into mimickers of bruises and mimickers of burns (Table 1).

Table 1.

Cutaneous mimickers of physical child abuse

Medical conditions that can present with cutaneous lesions mimicking bruises	Medical conditions that can present with cutaneous lesions mimicking burns
• Bleeding diathesis – Platelet disorders – Coagulopathies – Vitamin K deficiency – Chronic liver disease• Malignancies – Hematological – Neuroblastoma• Collagenopathies – Ehlers-Danlos syndrome – Osteogenesis imperfecta – Vitamin C deficiency• Autoinflammatory – Henoch-Schonlein purpura – Dermatomyositis – Acute hemorrhagic oedema of infants – Erythema multiforme – Erythema nodosum• Congenital cutaneous lesions – Mongolian spots – Haemangioma• Other dermatological conditions – Inflammatory linear verrucous epidermal nevus – Allergic contact dermatitis – Growth striae – Phytophotodermatitis	• Infections – Bullous impetigo – Staphylococcus scalded skin syndrome• Chronic bullous diseases – Epidermolysis bullosa – Bullous pemphigoid – IgA linear dermatosis – Stevens-Johnson syndrome• Others – Phytophotodermatitis – Contact dermatitis – Incontinentia pigmenti – Urticaria pigmentosa

Medical conditions that can present with cutaneous lesions mimicking bruises

Medical conditions that can present with cutaneous lesions mimicking burns

• Bleeding diathesis – Platelet disorders – Coagulopathies – Vitamin K deficiency – Chronic liver disease• Malignancies – Hematological – Neuroblastoma• Collagenopathies – Ehlers-Danlos syndrome – Osteogenesis imperfecta – Vitamin C deficiency• Autoinflammatory – Henoch-Schonlein purpura – Dermatomyositis – Acute hemorrhagic oedema of infants – Erythema multiforme – Erythema nodosum• Congenital cutaneous lesions – Mongolian spots – Haemangioma• Other dermatological conditions – Inflammatory linear verrucous epidermal nevus – Allergic contact dermatitis – Growth striae – Phytophotodermatitis

• Infections – Bullous impetigo – Staphylococcus scalded skin syndrome• Chronic bullous diseases – Epidermolysis bullosa – Bullous pemphigoid – IgA linear dermatosis – Stevens-Johnson syndrome• Others – Phytophotodermatitis – Contact dermatitis – Incontinentia pigmenti – Urticaria pigmentosa

The initial and most significant step in suspected child abuse is to differentiate accidental trauma from non-accidental trauma. In inflicted bruising cases, both the bruising site and ambulatory status of the child can give clues to the cause. Accidental bruising is typically found in ambulatory school-aged children in areas susceptible to injuries such as the knees, anterior face of the tibia, forehead, bridge of the nose, and over any bony prominence. On the other hand, the incidence of bruising declines substantially in non-ambulatory children, especially those under the age of six months. Inflicted bruising is usually suspected if present in protected areas such as arms, lateral and posterior aspects of the thigh, soles of the foot, eyes, ears or mouth.⁶ Moreover, cutaneous lesions caused by medical conditions that mimic cutaneous lesions of child abuse need to be differentiated from those caused by true physical abuse of the child.

One of the major causes of non-inflicted bruising is bleeding disorders. Patients may present with spontaneous bruising in protected areas or bruising post minor trivial contact in susceptible areas. These conditions might be due to an inherent error in coagulation factors, platelet production or function, or due to acquired conditions such as immune thrombocytopaenic purpura, vitamin K deficiency, hepatic diseases or haematologic malignancies. A thorough history supported by meticulous physical examination and appropriate laboratory testing can help physicians differentiate these conditions from child abuse.⁶

In children younger than the age of two, the most common type of solid tumour is neuroblastoma.² Several cases have been reported to be mistaken for child abuse due to their orbital metastasis manifesting as bilateral periorbital oedema or ecchymoses in the event of negative physical examination for any palpable masses.^3,7 A 10-month-old infant, initially suspected to be a case of child abuse, was diagnosed with scintigraphic raccoon eyes due to neuroblastoma upon bone scan investigation.⁸

Connective tissue disease causing capillary fragility can also mimic inflicted bruising. Inherited collagenopathies such as osteogenesis imperfecta and Ehlers-Danlos syndrome (EDS) can be falsely implicated as child abuse. EDS is a connective tissue disease characterised by hypermobile joints, elastic skin, easy ecchymosis, and scarring. They commonly present with bruising in susceptible areas post minor accidental injury.^3,6

Two cases of suspected child abuse were reported of a 13-year-old child and another 7-year-old child, where both patients presented with atrophic scars of different healing stages on the face and lower limbs. Further questioning revealed history of spontaneous bruising, bruises caused by minor trauma, and paternal family history of hyperextensible joints. Upon dermatological examination, patients demonstrated findings suggestive of classic EDS such as hypermobility of the joints and “cigarette paper” scars with underlying bruises on the knees and over the shins. Child abuse allegations could have resulted in major psychosocial consequences had they been wrongfully diagnosed.^9,10

Another connective tissue disease manifestation that might be confused with inflicted injuries is Gottron papules in patients with dermatomyositis. An acquired condition that similarly results in the weakening of capillary vessels is vitamin C deficiency, also known as scurvy. Other symptoms of scurvy include fatigue, anaemia, gum swelling, and bleeding.⁶

Henoch-Schonlein purpura is an autoimmune multisystem inflammatory disease mainly affecting small vessels. It presents as a prodrome of fever, headache, abdominal pain, and arthralgia followed by a rash commonly involving the buttocks and legs. The rash typically starts as erythematous papules and evolves into palpable purpura, which may coalesce, mimicking an inflicted ecchymotic lesion. Other inflammatory disorders that may imitate inflicted bruising are erythema nodosum, erythema multiforme, erythema marginatum, and acute haemorrhagic oedema of infants.³

Many congenital cutaneous lesions may be mistaken for bruises. Mongolian spots are grey-bluish hyperpigmented lesions usually present in the lumbosacral region, which can be mistaken for bruising, especially if present in atypical sites. However, a thorough history revealing presence since birth and the absence of bruising evolution can rule out child abuse.^2,3 Another lesion is congenital haemangioma, a benign vascular tumour that grows in size during the first year of life and starts to regress by 12-18 months of age. Common sites are the scalp, face, and genital area.^4,6

Phytophotodermatitis is a result of a phototoxic reaction which occurs due to the activation of furocoumarins when exposed to ultraviolet A waves of sunlight. Hyperpigmentation and vesicular eruption of the sun-exposed skin occur after coming into contact with these substances, resulting in lesions in the form of small fluid-filled blisters or large tense bullae, with or without an erythematous background. These lesions may present in a linear pattern or hand form, raising the suspicion of inflicted burns or bruising due to hand slaps.^3,11,12

Citrus fruits are the most common culprit leading to photodermatitis, with lime juice being in the lead. An 18-month-old child presented with hyperpigmentation mimicking bruises on both the upper back and axilla, with a negative past history of any haematological conditions. After acquiring a detailed history, the mother reported handling lime prior to cradling her child, and the pattern of lesions corresponded to the way she carried the child. Multiple cases of suspected child abuse were documented in children with truncal lesions resembling fingerprints, only to reveal after a thorough history recent contact with limes or sun exposure.¹¹

Other furocoumarin-containing plants such as figs, celery, and hogweed have also been reported to cause similar phototoxic reactions. Numerous cases have been documented of children unintentionally coming into contact with these plants while playing outdoors, or while helping with gardening chores.^12,13 Hogweed, or cow parsnip, has been implicated in a case of an 11-year-old child who presented with tense tender bullae after clearing weeds near his home.¹²

Staphylococcus aureus is a common skin pathogen. It causes a wide range of skin infections, which may resemble intentional burns. Bullous impetigo is a localised skin infection that may mimic infected cigarette burns in particular. A macular skin lesion evolves into a vesicle that enlarges into a bulla, which easily breaks, leaving a crust around the normal skin or a shallow ulcer. In comparison, cigarette burns are deep and well demarcated. Staphylococcus scalded skin syndrome is another staphylococcus induced systemic reaction. It occurs after the release of toxins into the circulation leading to bullous formation and desquamation.^2,3,6

In this context, a case of suspected maltreatment was documented in the United Kingdom. A 2-year-old child presented with a 4 × 4.5 cm circular skin lesion that appeared suddenly on her upper arm, which was associated with central crusting. Upon careful dermatological evaluation, the lesion was properly distinguished from a cigarette burn and a diagnosis of bullous impetigo was made.¹⁴

An inherited condition causing bullous formation that may resemble burns is epidermolysis bullosa. It is subdivided into various types and subtypes that can present in many ways.^3,4 Another chronic bullous condition is IgA linear dermatosis, an autoimmune disease, presenting as annular erythema and blisters around the mouth, on the lower abdomen, thighs, or the genital area. It usually remits with the onset of puberty.³ Bullous pemphigoid is less common in children but may occur. Lesions frequently erupt in a symmetrical pattern on the flexors. Stevens-Johnson syndrome is an acute adverse drug reaction that is potentially fatal. It may be mistaken for extensive burning if a thorough drug history is not obtained.⁶

It is also important to consider complementary medicine practices used in different cultures as therapeutic remedies. These usually result in ecchymosis or burns, imitating child abuse. Cupping is a practice used worldwide, including western countries, that involves placing a heated cup to the skin near the site of pain, creating a vacuum resulting in petechia or bruising.^2,4 Another practice used in Far-East countries is coining or spooning. A linear patterned petechia or ecchymosis is produced by rubbing a heated metal, coin, or spoon, against thoroughly lubricated skin using mentholated oil.^2,4 A common practice in the Middle-East, is skin cauterisation. A heated metal is applied to the site of pain, aiming to inflict a burn, which is believed to treat the underlying symptom.^3,15

Conclusion

There are different medical conditions presenting with cutaneous lesions that can be falsely mistaken for bruises or burns. The clinical practitioner must investigate for alternative explanations when child abuse is suspected. Differentiating these medical conditions from physical child abuse requires physicians to be familiar with the potential clinical, laboratory and radiological clues linked with these conditions. Reaching a proper diagnosis can save children and their families from long-term consequences such as disruption of the family, long-lasting stigma towards the child and family, and unnecessary legal implications.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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