1 CPD credit: Child protection in dermatology

1 CPD CREDIT Complete the full activity at mimslearning.co.uk/dermatology

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.

Examination findings

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.

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)

Differential diagnoses

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.

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

References
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.