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An. Bras. Dermatol. vol.86 no.3 Rio de Janeiro May/June 2011
Child abuse: skin markers and differential diagnosis*
Roberta Marinho Falcão GondimI; Daniel Romero MuñozII; Valeria PetriIII
IPhD student, School of Medicine, University of São Paulo (FMUSP) - São Paulo (SP), Brazil
IIProfessor, Department of Forensic Medicine, Medical Ethics, Social and Occupational Medicine, School of Medicine, University of São Paulo - São Paulo (SP), Brazil
IIIProfessor of Dermatology, Federal University of São Paulo (Paulista School of Medicine-UNIFESP) - São Paulo (SP), Brazil
Reports of child abuse have increased significantly. The matter makes most physicians uncomfortable for two reasons: a) Little guidance or no training in recognizing the problem; b - Not understanding its true dimension. The most common form of child violence is physical abuse. The skin is the largest and frequently the most traumatized organ. Bruises and burns are the most visible signs. Physicians (pediatricians, general practitioners and dermatologists) are the first professionals to observe and recognize the signs of intentional injury. Dermatologists particularly, can help distinguish intentional injury from accidental, or from skin diseases that mimic maltreatment.
Keywords: Burns; Contusions; Ecchymosis; Domestic violence; Sexual violence
The concept of "battered child syndrome" was introduced by Kempe in 1962 to define the situation in which multiple accidental traumas, not caused by external conditions unexplained by anatomic and pathological injury, are associated with physical violence perpetrated by caregivers. 1.7
Abusive conduct, mistreatment, neglect and domestic violence are rarely considered among likely or differential diagnoses, unless they indicate sexual abuse or when sexually transmitted diseases are confirmed. The recognition of physical and psychological abuse, however, should be done by child care agencies, through a multidisciplinary approach, seeking to minimize or eliminate the suffering of the child, promoting and ensuring its well-being and even survival.
Violence against children tends to be an uncomfortable topic for many doctors, in part by the lack of training to recognize and deal with the problem.8 The skin is the first organ to be affected in physical aggression and it is the most frequently involved, causing skin manifestations to be the most recognizable forms of abuse. 9-13 About 90% of victims of physical abuse show skin lesions on examination.11 The dermatologist should know the signs of physical abuse and the differential diagnoses (skin and/or systemic diseases) that can mimic or simulate the main skin lesions resulting from physical violence.
There are few publications on the subject, especially in Latin America. This review aims to assist in differentiating the skin signs of child abuse (physical and/or sexual) and the main mimicking clinical conditions.
Reports of mistreatment of children have grown at an alarming rate in recent decades: about 60,000 cases in 1974, 1.1 million in 1980 and 2.9 million in 1992. 10 In the United States, more than three million cases of child abuse or neglect are reported annually, 14 and at least 2,000 children die due to abuse.15 The rapid growth in the number of reported cases may be due to the recognition of the problem and complaints. Still, it is estimated that for every victim identified, there are two unreported or even unnoticed cases. 8
Child abuse is defined by the Center for Prevention and Treatment of Child Abuse (USA), such as 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. 16 Recognition of the early signs of abuse is imperative, and often the doctor is the first and only professional to have contact with the situation. In addition, about 30 to 70% of abused children are subject to subsequent injuries, that is, less severe forms of abuse tend to evolve into progressively more severe abuse, unless there is early intervention. 17
The diagnosis of child abuse is part of the International Classification of Diseases (ICD10) 18 and must necessarily be distinguished from other diseases.9 However, many skin signs may be the product of accidents, of events that are common in childhood, and of strictly medical conditions. 6
Diagnostic investigation of child abuse resembles that of other medical conditions and details of the child's history can provide a strong indication of violence 9.17 Suspected abuse can have significant indirect evidence: 1) the explanations about the injuries found are vague or absent, 2) versions of the facts differ from one moment to another, 3) the perpetrator(s) of injury take at least two hours to seek medical help or use emergency services without reason or for petty reasons, 4) history of frequent visits to the emergency room, 6) repeated fractures, and 7) reported history that is inconsistent with the physical findings. 8.19
There are four major types of abuse: physical, sexual, emotional and neglect. In almost all cases of physical abuse 8 skin signs appear, and the most common are ecchymosis, lacerations, abrasion, burns, bites, traumatic alopecia, and oral trauma. 8.20
ECCHYMOSIS AND DIFFERENTIAL DIAGNOSES
Ecchymosis is the most common sign of abuse, 9,10,21 despite being frequently found in any active child without any relation to abuse or neglect. Accidental ecchymosis on the knees and anterior face of the tibia 9 and any bony prominence, such as the forehead and the backbone, are common.8 Children with less than three ecchymoses measuring less than 1.0 cm do not usually have a history of violence or abuse. 22 However, ecchymosis in places that are relatively protected, such as the arms and posterior and medial faces of the thighs, hands, ears, neck, genitals and gluteal region can signal abuse, especially ecchymoses that are extensive and of varying ages.23
Accidental injuries require motor skills. Therefore, ecchymosis in children under six months of age is rare because they do not have great mobility. One or more soft tissue ecchymoses on the preambulatory child can be correlated with abuse. Accidents tend to increase with mobility, especially in the legs and forehead. Accidental ecchymoses of the head are uncommon in preambulatory and school children, but they are not rare in children who have started to walk and who are still unsteady. Therefore, it should be known that any soft tissue injury in preambulatory children is highly correlated with abuse. 9
Ecchymosis on the ears and genitalia is indicative of abuse, because these areas are rarely injured by accident. 20 Accidental abdominal ecchymoses are rare, due to the flexibility and muffling power of fat. When present, they indicate a strong impact and internal injuries should be investigated, as mortality rate reaches 50%.24
Ecchymoses with a pattern (specific form) constitute strong evidence of abuse. They tend to be located in the gluteal region, front legs and back. They may be linear, round, parallel, or in the pattern of a strap, and reflect, at least partially, the shape of the object used to inflict injuries (ropes, belts, buckles), helping to differentiate between accidental and provoked ecchymosis. 12 However, some diseases can cause ecchymoses or persistent erythema in protected areas without corresponding to abuse. Chart 1 shows the main skin diseases (localized or systemic) that may mistakenly lead to the wrong diagnosis of child abuse) 8.
The appearance of ecchymosis depends on the time of evolution of the bruising, location, depth and skin aspect 25,26. The process of resolution depends on other variables such as use of anti-coagulants, applied force, age, vascularization of the adjacent skin and comorbidities 27. The use of Wood's light has been an auxiliary method in the visualization of light bruises or those invisible to the naked eye 28.
Attempted strangulation can cause swelling and distal petechiae on the labial commissure of mouth. Ecchymoses with a digitiform aspect can be observed in the arms. Original pressure points in pinching are white, demarcating the contours of the aggressor's fingers, pressuring the blood laterally 29. Spanking may produce linear and parallel purpuric lesions with a small triangle at the base, representing the interdigital space 30.
The location, number, size and color of ecchymoses can be confused with lesions caused by abuse.14,31-51
BURNS AND DIFFERENTIAL DIAGNOSES
Burns comprise about 5 to 22% of all physical abuse 52,53. They represent between 8 and 25% of all pediatric burns and seem to be more common in children under 3 years old. 54,55
Intentional contact burns are deeper, they may be multiple and with well-defined margins. They are usually produced by hot iron, radiators, hair dryers, hair curling irons, stoves or immersion in boiling water. Contact burns with well defined margins and uniform depth, usually located in protected areas, are suggestive of abuse. 55
The location of the burn, although not a pathognomonic sign, may be useful to exclude the practice of abuse. Face, hands, legs, feet, perineum and gluteal region tend to be preferred sites of abuse. The perineum and gluteal region are rarely affected in accidental burns 53.54. The anterior trunk and upper limbs are common sites of accidental burns (Fig. 1A). Abusive burns tend to involve the face, dorsum of hands, the lower trunk and lower limbs. Accidental burns of the hands most commonly affect the palms and the anterior surface of the fingers in contact with the hot object. 56
Intentional cigarette burns are common. They are approximately 7 to 10mm in diameter, are well demarcated and have a central crater. As they injure the dermis, they usually regress forming a scar. They usually present as grouped lesions on the face, hands and feet 53. When accidental, they tend to be oval, eccentric and more superficial, because the child reacts quickly to the pain. 54 (Figure 1B).
Burns caused by immersion in hot water can be accidental or intentional. Forced immersion in hot water preserves the folds and the resting point of the gluteal region, resulting in a symmetric delimitation that tends to show accurate limits and uniform depth.17. Forced immersions of the limbs present as "glove", or "sock" burns, and "zebra stripes" 53.55" are the result of "creases" caused by the flexed position (Figure 2).
Erythematous-edematous and/or vesiculobullous lesions may mimic physical abuse caused by objects or hot liquids. Some studies show the difficulty in differentiating between intentional burns and skin diseases that mimic abuse. 14, 57-71 Chart 2 presents a brief discussion of such works.
OTHER SIGNS OF VIOLENCE AGAINST CHILDREN
Bruising, abrasion and burn can be identified in the mouth (lips, cheek mucosa, palate). Oral traumas are reflected more by hematomas than by ecchymoses. 72 Erythema or petechiae on the palate, especially in the transition between the soft and hard palate, may point to the possibility of forced oral sex.7.Lip or lingual frenulum fissures may indicate trauma by forced feeding or other type of violence, especially forced oral sexual practice. 58.73. Despite the fact that evidence of lesions in the oral cavity indicate sexual abuse, such signs are not often observed 74. Cutlery, cups, or hot foods can cause burns or lacerations in the oral cavity and even fractures or tooth loss. These children also tend to show signs of dental neglect 8.
Bites raise suspicion for abuse and require a thorough examination of the victim. Classical marks are semi-circular, and the punctures caused by the canines may be prominent. Since the normal distance between the maxillary canines in adults is 2.5 to 4.0 cm, one can consider that bites with intercanine distance greater than 3.0 cm are probably inflicted by adults. Shorter distances suggest that the bite might have been caused by a child. 75. The forensic dentist can make molds of the dental arch and/or collect local swab (collection of DNA material to investigate the saliva of the aggressor). Animal bites are distinguished by being deeper and more lacerating than human's.76
Alopecia can be another indicator of abuse and mistreatment. It has a traumatic origin, by the intentional pulling of hair, as punishment, or the act of pulling the child by the hair. Violent pulling can produce petechiae, edema of the hair scalp and acute hematoma 8, with pain on palpation and irregular contours of localized hair loss. 77 Tinea capitis, traction alopecia, trichotillomania, loose anagen syndrome and alopecia areata are differential diagnoses 20.
Neglect is more common than overt physical violence and may eventually manifest itself as skin lesions 78. Neglect is defined by the lack of provision of the basic needs of the child. It is usually chronic, jeopardizing the nutrition, clothing, education and health of the child. On clinical examination, there is marked loss of subcutaneous tissue, dermatitis (such as persistent ammonia dermatitis), scarification and/or skin sores caused by chronic hypovitaminosis and poor hygiene, often with pediculosis 9, scabies, pyoderma and fungal intertrigo. 80 These children are often not immunized according to the vaccination schedule and show various signs of abuse. 20
SEXUAL ABUSE AND DIFFERENTIAL DIAGNOSES
About 1% of children suffer some form of sexual abuse every year, resulting in a prevalence of victims around 12-25% of girls and 8-10% of boys until the age of 18 years. 81 The diagnosis of sexual abuse and the protection of the child partly depend on the promptitude of the physician to consider abuse as a possibility. 82 Despite an increase in the number of cases, many doctors are not familiar with their recognition and don't know how to differentiate them from medical conditions that mimic sexual abuse 20.
Physical examination of the genitalia of boys and girls who have suffered sexual abuse reveals erythema, ecchymosis, excoriations and lacerations. Some findings such as erythema and hyperpigmentation are frequent in the perianal region, and they are not always associated with sexual abuse . Accurate clinical history can differentiate the two conditions.
There are many differential diagnoses of sexual abuse against children and among them are other types of genital injury, infections, dermatological diseases, congenital conditions affecting the perineal region and diseases affecting the urethra and/or anus. 83 When sexual abuse is suspected, it is essential to remember that various dermatological diseases cause erythema, ulcers, friability or bleeding in the perigenital region. 20 Similarly to other lesions caused by trauma in more exposed areas of the body (ecchymoses and burns), lesions in this region can generate diagnostic questions and even undue accusations of abuse, as shown by the works listed in Chart 3.20, 84-101
The confirmation of sexual abuse is difficult and there are few cases in which the clinical diagnosis is unquestionable without the aid of police and forensic investigation. Genital trauma or sexually transmitted diseases in the child (syphilis, HIV infection, gonococci and Chlamydia) provide strong evidence for the diagnosis of sexual abuse when vertical transmission, transmission through the birth canal and by blood transfusion are excluded. Positive forensic findings and the presence of semen or sperm in the genital region confirm sexual contact. 102
In dermatological practice, genital warts tend to raise suspicion of child sexual abuse. The incidence of child infection by HPV types that cause genital warts follows the increase in the number of cases of this infection in adults. Sexual abuse should always be considered, even if infection by other means is frequent. Until the age of two perinatal transmission is possible, through unsanitary handling by the caregiver (eg, diaper changing) and even sexual abuse. After this age, even when perinatal origin and unsanitary handling are considered, the possibility of abuse as a cause of condyloma acuminata increases 20.
PSYCHOLOGICAL CONSEQUENCES OF CHILD ABUSE
Child abuse is a public health issue of great social and family impact 103. The events can be intra-or extra-familial and psychological damage to the victims and families is indelible. Health professionals, social workers, educators and lawyers are intimately involved in these events and multidisciplinary action is imperative.
Abuse against the child or adolescent may have different consequences, depending on whether it occurs in an intra-or extra-familial context, which explains the different degrees of difficulty in detection and diagnosis, requiring different strategies of intervention with victims, abusers and family, and always taking into account the interests of the child. The different sequelae depend on characteristics of the victims, abusers and the abuse itself (type, duration, frequency). 104
Some aspects of intra-familial abuse may constitute aggravating factors: younger age of the victim, greater proximity to the offender, greater degree of emotional violence. Loss of security in the home/family is a profound threat to the development of children and adolescents. In addition, family abuse is diagnosed later, due to lower visibility. Offending caregivers tend to minimize the physical signs of abuse. Thus, evidence based on physical examination tends to be scarce. In these situations, after report of the suspicious case, an expert's opinion on forensic psychology is paramount to evaluate the victim's testimony and confirm its veracity, as well as to conduct psychological tests that could confirm the events in a non-verbal way. 104
In order to characterize the sequelae of maltreatment, a psychobiological model has been proposed that emphasizes a cascade of events: environmental stressors such as child abuse would provoke key changes in biological systems, particularly the neurological system, causing problems in the auto-regulation of behavior. The devastating psychological effects would result, in the long run, in excessive anxiety, depression, cognitive and language distortions, somatization, dissociation, aggression, impulsivity, distrust, attachment disorder, substance abuse, emotional instability, self-destructive behavior, suicide, personality disorders, eating disorders, obesity, risky sexual practices and criminal behavior. 105
Pediatricians and general practitioners, in general, must be prepared to respond to incidents of child abuse because they are very frequent worldwide, regardless of socioeconomic status. Physicians and health professionals should identify the signs of abuse and take legal action when there is strong suspicion or confirmation. The diagnosis should be optimized, criteria must be established and progressively more specific, seeking to reduce the causes of error.
The anogenital region should be routinely and accurately examined, considering the emotional sensitivity of the child and its family. Inspection should aim at detecting diseases and possible injuries. Confirmation of abuse depends on medical knowledge, and the physician must insist on judging the chances of misdiagnosis. While assessing the consequences of trauma and other forms of abuse bylistening to and believing in the report of the child and any informer and being willing to testify and notify when needed, the physician must know the differential diagnoses or diseases that can mimic abuse.
Suspicion of physical and/or sexual abuse has a multidisciplinary nature; it requires the involvement of a pediatrician or general practitioner, a dermatologist, a forensic pathologist, a gynecologist (when applicable) and a social worker. The diagnostic confirmation and exclusion of dermatological diseases must precede report to judicial authorities, 99 bearing in mind that error or omission may cost the lives of children and undue child abuse charges could cost the reputation of an innocent adult. 20.
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Mailing address: Received on 23.03.2010.
Approved by the Advisory Board and accepted for publication on 201.09.2010. * Battered child syndrome.
Rua Miguel Barra, 800 Ap. 400 Tirol
59014-590 Natal RN Brasil
(84) 9998-7872 ou (11) 8470-6558
Conflict of interest: None
Financial funding: None
* Work conducted at the School of Medicine, University of São Paulo (FMUSP) - São Paulo (SP), Brazil.
Received on 23.03.2010.
Approved by the Advisory Board and accepted for publication on 201.09.2010.
* Battered child syndrome.