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Dermatologic clues may point to clinical signs of child abuse

A detailed history and looking for signs of abuse in specific locations can help dermatologists arrive at a diagnosis of child abuse, says a professor in pediatric dermatology speaking in San Francisco at the annual meeting of the American Academy of Dermatology.

“Taking the history is very important,” said Arnold Pieter Oranje MD, PhD, in an interview with THE CHRONICLE. “You have to assess if there is real skin disease.”

Dr. Oranje practices pediatric dermatology at Erasmus Medical Center in Alkmaar, The Netherlands.

Bruises are one of the most common signs of physical abuse, but clinicians have to be able to distinguish between bruises that can occur in a child while walking, crawling, or at play with other children, said Dr. Oranje.

“If the bruises occur on sites that are not places where bruises are normally expected to occur, that should raise suspicion,” he said. “It is about making sure the history matches the presentation. Child abuse is a diagnosis of exclusion and ruling out other diagnoses.”

It is very unlikely that infants less than six months of age would have bruises, so the presence of bruises in children this young raises suspicion of potential child abuse, according to Dr. Oranje.

If a child has a condition such as hemophilia or idiopathic thrombocytopenic purpura, that child is more likely to bruise, and that may explain the bruising, said Dr. Oranje.

Indeed, a percentage of cases that are referred for physical abuse are actually determined to be hematologic in nature.

The phenomenon of phytophoto dermatitis may be confused with bruising. Psoralens, for example, can be contained in fruit juices, and if children’s skin is exposed to these psoralencontaining juices, and children then go outside and exposed to sunlght, they can develop blistering or hyperpigmentation that may resemble bruising.

Exclude underlying conditions

Other signs of child abuse include broken bones, but clinicians have to exclude any underlying conditions that may predispose children to developing broken bones.

“The child could have osteogenesis imperfecta,” said Dr. Oranje. “It is a rare genetic disease, but it can be a possible explanation of why the child has broken bones.”

In assessing burns or cuts, clinicians have to think about the common presentation of these dermatological insults compared to uncommon presentations of these insults to determine if they

are a result of child abuse, explained Dr. Oranje.

“Burns can be accidental, such as a child having a burn on his or her hand because of touching the stove or putting a hand in a pot of hot water,” said Dr. Oranje.

The location of a burn is significant in evaluating if a burn has occurred accidentally or because of child abuse, said Dr. Oranje.

“If the burn cannot be explained by a splash of hot water, and is in a location like the back, it is an injury that should be recognized [as possible child abuse],” he said.

There are some specific patterns that may appear on the body that suggest abuse, for example, if a child was hit with a belt buckle.

Apart from physical abuse, clinicians should also identify if there are any signs of neglect, such as if child is undernourished or appears as if he or she has not been bathed, said Dr. Oranje.

Sexual abuse is another form of abuse that clinicians can potentially detect in children, said Dr. Oranje.

The presence of genital warts, for example, could be a sign of sexual abuse in pediatric patients, particularly younger patients.

If clinicians have some doubts of whether or not a child is being physically abused, one strategy is to refer the child to another physician to get a second opinion about possible abuse.

Previously published in The Chronicle of Skin & Allergy.

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