It is important for every healthcare professional working with children to consider child abuse as a differential diagnosis and to be able to deal with it appropriately.
Having a good working knowledge of dermatology helps clinicians to distinguish skin disorders from inflicted injuries.
This article describes different types of child abuse, explains important aspects of taking a history and carrying out an examination of children with dermatological conditions, indicates factors that make child abuse more likely and where to seek advice and support if you suspect child abuse.
It also outlines dermatological differential diagnoses that might be mistaken for child abuse.
Child abuse, child protection, dermatological conditions, paediatric dermatology
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High-profile child abuse deaths due to multiple injuries, such as those of Baby P and Daniel Pelka, are sadly all too frequent.1,2 Although in retrospect, their diagnosis might seem obvious, it is not always simple to put all of the pieces of the jigsaw together and build up a full picture. Parents may provide deliberately misleading information, which makes diagnosis more difficult.
Lesions resulting from abuse can be confused with skin disorders, as in the case of Victoria Climbié, whose lesions from being beaten were wrongly diagnosed as scabies.3 In 2003 Lord Laming stated that the agencies involved in safeguarding Victoria suffered from ‘widespread organisational malaise’ and that communication between professionals had been poor.3 He challenged every professional to think the unthinkable and consider child abuse as a differential diagnosis.3
Although time is limited in an outpatient department or GP surgery, it is vital to take a few minutes to ensure nothing is overlooked where children are concerned. A detailed history and thorough examination will reveal key pointers.
Bruising may be the result of non-accidental injury (Photograph: Heart of England NHS Foundation Trust)
Types and frequency of abuse
A child may be subject to more than one form of abuse, either at the same time or sequentially.4,5 In 2014, more than 50,000 children were identified as needing protection from abuse in England.4 Estimates are that for every child identified, another eight are actually suffering abuse.4
Types of abuse include physical, emotional, neglect, sexual, female genital mutilation (FGM) and fabricated or induced illness.5,6 In the latter, the history suggests a medical problem, but the child is always well on examination. Commonly, there is medical knowledge and a similar pattern of ill health among family members.
Important factors in the history
Box 1 outlines some features in the history that should raise concerns. When taking the history, ask how skin lesions happened, when, where and who was present.
The child’s past medical history may give vital clues and explain examination findings, for example, blistering in a child with epidermolysis bullosa, bruising in a child with a bleeding disorder or burns in a child with pain insensitivity.7
Always take a social history and think about risk factors (see box 2), although abuse can occur in any household. Good notekeeping is essential because later on, much may be made of discrepancies in the history, particularly between doctors.
|Box 1: Worrying features in the history4,5|
|Delay between injury occurring and seeking medical help, or medical help not sought
|Vague account of how injury occurred, which lacks detail and changes with each person telling it|
|Abnormal parental affect, such as being hostile or abusive to medical staff, and refusing treatment or referral|
|Trigger factors, such as child being a difficult feeder, crying repetitively or having an underlying chronic disorder|
|Explanation offered is not consistent with type of injury|
|Box 2: Risk factors for abuse4,5|
|Socially disadvantaged or isolated
|Current or previous child protection plan (social services ?will have a record of this)|
|Parental mental health problems|
|Unrealistic expectation of child by parent|
|Parental history of abus|
As part of routine practice, make a note of any skin lesions, especially because the child may be seen by a different doctor at each visit.
A large area of bruising on one occasion may be compatible with an injury, such as falling downstairs. However, if bruising is present on a subsequent occasion, this raises concerns about non-accidental injury, or that the child is not being adequately supervised. Smaller bruises that may be fading can often go unrecorded. Body diagrams form an essential record of skin changes and photographs are helpful as a visual record.5,6
If you believe a child under one year old is not thriving, plot their height, weight and head circumference on a growth chart. Emotionally abused children tend to be of short stature.
Observe the child’s appearance and note whether they are unkempt, wearing filthy clothes and/or behaving inappropriately, such as being aggressive or indiscriminately friendly and seeking physical contact with strangers.
If sexual abuse is suspected, examination of the child’s genitalia should only be carried out by a clinician who is an expert in this field. Perianal warts can cause concern. If there is a negative social history, no signs or history of abuse, and the lesions are somewhat distant from the anus and were acquired at less than 18 months of age, it is likely they have been innocently acquired.7
It is essential to be familiar with patterns of dermatological disease and their presentation in childhood, including rarer disorders. Common conditions may cause concern, for example, bullous impetigo and Mongolian blue spots if at sites other than the lower back.6,7 A careful history is key because the latter do not change over time, an important factor in trying to distinguish lesions suspicious of cigarette burns from those due to rare childhood conditions such as Degos disease (malignant atrophic papulosis).8 Sequential photographs are helpful.
Bullous impetigo may be the cause of suspicious skin marks (Photograph: Heart of England NHS Foundation Trust)
Bruising and burns
Bruising is present in 90% of children who are physically abused and the colour, distribution and pattern of bruises should be noted, although colour does not reliably age the bruise. Paint, pen marks or dye from clothing can look like bruises, but wash off. Use an antiseptic wipe if in doubt.
Random distribution of bruises on the legs and arms is common in young, mobile children.5,6 Bruising in non-mobile children, however, should be carefully considered. Box 3 lists sites and patterns of bruising that should raise concern.
|Box 3: Bruising and other marks on the skin4,5|
|Sites where bruising or other marks are of concern
||Patterns of bruising caused by non-accidental injury
|Face/head of a child less than one year old
||Fingertip bruising, often caused by grabbing
|Head and neck in all children, especially:
– Sides of the face and ears, a common place for slap marks
– External ear
– Lower jaw and mastoid
– Black eyes
|Buttocks/lower back/outer thighs (related to punishment)
||Slap marks – finger-sized linear marks with a stripe effect
|Abdomen (being kicked when on the floor)
||Pinch marks – two crescent-shaped bruises facing each other
|Inner thighs (child sexual abuse)||Marks of implements – for example, belt or strap leaves parallel-sided marks tending to curve with body contours; ties and ligatures cause circumferential bands around limbs
|Poking marks – fingernails may cut the skin; fist marks cause diffuse and severe bruising
|Bites – animals usually cut, puncture or tear the skin, whereas humans leave crescent-shaped bruising and individual tooth marks in fresh lesions. Marks vary with site and any movement at the time of injury
|Torn labial frenula
|Bizarre marks due to being hit when clothed, with the pattern of clothing fabrics appearing on the skin
|Kicks – result in large, irregularly shaped bruises on lower half of body|
Non-accidental burns tend to affect the face, head, buttocks, genitalia, hands and feet. Crusting lesions around the mouth may be due to hot food being pushed into the face.
Punishment, such as for soiling or bedwetting, may be by dipping the child’s buttocks into a bath filled with very hot water. In this case, the centre of the burn tends to show sparing where the buttocks have been pressed on the bath, like a doughnut. A glove and stocking distribution, with no splash marks and clear demarcation, is seen when forced immersion of the hands and feet in hot water has taken place.
Non-accidental hand injuries often affect the dorsum, for example, if a hand is held under hot water, whereas accidental burns typically affect the palmar surface, for example, as a result of holding the bar of an electric fire.
Accidental cigarette contact tends to leave an area of redness with a tail. This is easily differentiated from the deep crater produced by holding a cigarette in contact with the skin. To distinguish burns from rare disorders such as Degos disease, follow-up will show that burns heal while the latter do not.8
Female genital mutilation
FGM was made illegal in the UK by the Female Genital Mutilation Act 2003.9 FGM should be considered if a girl presents with genital lesions or a sore vulva, or has difficulty walking or sitting down.9 Risk factors for FGM are:
- Belonging to a community which practises FGM
- Family plans for a holiday with extended leave from school
- The girl talks about a forthcoming special celebration
- The girl’s mother or sisters have had FGM
Dermatitis artefacta may be a differential diagnosis (Photograph: Heart of England NHS Foundation Trust)
A number of skin disorders might be mistaken for physical or sexual abuse. The list in box 4 is by no means exhaustive because this is beyond the scope of this article.
|Box 4: Differential diagnoses for skin findings6,7|
|Schamberg disease (progressive pigmented purpura)
|Haematological disorders (idiopathic thrombocytopenic purpura, leukaemia cutis, blueberry muffin lesions)
|Mongolian blue spots, especially other than on lower back|
|Marks of concern on the skin|
|Vulval or genital vitiligo|
|Innocently acquired warts|
|Perianal streptococcal cellulitis|
What to do if child abuse is suspected
If abuse is suspected, this usually involves referral to the local paediatric department, either in the community or at a nearby hospital. However, every hospital trust, community clinic and GP surgery will have its own child protection policies, which should be consulted and followed.10,11
Talking things over with the local child protection nurse or designated doctor for child protection is helpful, as is discussion with a more senior colleague.
Local safeguarding children boards can be telephoned for advice.12 If a referral is made, this should be put in writing within 48 hours.12 Child safeguarding is multi-agency and does not rely solely on the opinion of one person.
Child safeguarding is the responsibility of all healthcare professionals. Check that the history and examination findings are compatible and the history is in keeping with the development and age of the child, for example, a non-mobile child climbing into the bath unaided resulting in burns to both legs is not plausible. Each year, 50-100 children die as a result of child abuse in the UK and we need to do everything possible to reduce this number.
- Dr Helen Goodyear is consultant paediatrician, Heart of England NHS Foundation Trust and associate postgraduate dean, Health Education West Midlands
Competing interests: None declared
1. Coventry Safeguarding Children Board. Serious Case Review: Re Daniel Pelka. Overview Report. September 2013.
2. Lord Laming. The Protection of Children in England: A Progress Report. London, The Stationery Office, 2009.
3. Lord Laming. The Victoria Climbié inquiry. London, The Stationery Office, 2003.
4. NSPCC. Child protection in England.
5. Meadow R, Mok J, Rosenberg D (editors). ABC of Child Protection (fourth edition). Chichester, Wiley-Blackwell, 2007.
6. Bilo RAC, Oranje AP, Shwayder T et al. Cutaneous Manifestations of Child Abuse and their Differential Diagnosis. Berlin, Springer, 2013.
7. Al Jasser M, Al-Khenaizan S. Cutaneous mimickers of child abuse: a primer for pediatricians. Eur J Pediatr 2008; 167: 1221-30.
8. Moss C, Wassmer E, Debelle G et al. Degos disease: a new simulator of non-accidental injury. Dev Med Child Neurol 2009; 51: 647-50.
9 E-learning for Healthcare. Female Genital Mutilation.
10. GMC. 0-18 years: guidance for all doctors.
11. E-learning for Healthcare. Safeguarding Children.
12. HM Government. Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children.
|CPD IMPACT: EARN MORE CREDITS|
|These further action points allow you to earn more credits by increasing the time spent and the impact achieved
|Undertake the e-Learning for Healthcare safeguarding and protection modules at the appropriate level (one to three) for the work you carry out|
|Attend a Working Together safeguarding children course run by your local safeguarding children board|
|Read the Lord Laming review after the death of Victoria Climbié or the Daniel Pelka serious case review to enhance your knowledge of child abuse and why all healthcare professionals need to be involved in child safeguarding|
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