What Dermatologists are Taught About Child Abuse

Abuse allegations are a complex matter, and while doctors are trained to spot child abuse, there are instances where they get it wrong. This is true for pediatricians and psychologists, but also for dermatologists.

Because many common manifestations of child abuse are cutaneous, dermatologists are trained to recognize the signs of physical abuse. While the signs are often real, there are many situations where dermatologists misdiagnose abuse.

When dealing with abuse allegations, it's important to learn more about what dermatologists are taught so you can be well prepared to beat the allegations. Below, we’ll borrow from the following: Liborka Kos & Tor Shwayder. Cutaneous Manifestations of Child Abuse. Pediatric Dermatology Vol. 23 No. 4 311-320, 2006.

Skin Manifestations of Child Abuse & History Taking

Cutaneous signs are one of the most common signs of child abuse, and as such, dermatologists are taught to be alert about skin lesions. They are trained to recognize cutaneous manifestations of physical abuse, which include abrasions, human bites, bruises, lacerations, and burns.

Even though one or more of these signs are present in children who have been physically abused, dermatologists need to be able to differentiate accidental injuries from abusive ones. Physical evidence of abuse is often difficult to interpret; therefore, physicians need to check the history given by the caretakers to spot any red flags.

If the history is inconsistent with physical findings, dermatologists generally suspect abuse. However, physicians also need to keep in mind the developmental stage of the child when assessing the plausibility of the history. When assessing accidental injuries, for example, dermatologists need to make sure they are consistent with the child's stage of development.

Cutaneous Manifestations of Abuse

Bruising is the most common sign of physical abuse, but it's also widespread in active children. It's important for dermatologists to distinguish between accidental bruising, which is most often present on the anterior tibial area and over the knees, as well as the lower arms, hip, and forehead.

When bruising is present on areas such as cheeks, neck, ears, genitalia, buttocks, and upper arms, suspicions of abuse are raised. The presence of extensive bruises that seem to be of various age and bruising of the genitalia are hallmarks of abuse.

While some bruises may look consistent with physical abuse, it's essential to keep in mind that no part of the body is invariably spared in accidental bruising.

The age and development of the patient need to be taken into consideration when establishing patterns of abuse. Studies have consistently shown that babies under 6 months of age very rarely present accidental bruises due to the fact that they are not yet mobile. Increases in mobility, however, often lead to an increase in accidental bruises, with babies in walkers, for example, showing bruises on their shins and upper legs.

The shape of the bruise is another factor to consider because it might offer information about the shape of the object that inflicted it. When pattern bruising is present, it is usually a strong marker of abuse. Rods, switches, and wires leave linear bruises, whereas striking a child with a rope, belt, or extension cord leaves loop marks.

Besides bruising, bites and burns are other cutaneous manifestations of abuse. All bite marks raise suspicious of abuse, and dermatologists can differentiate animal bites from human ones. Burns account for approximately 5% to 22% of physical abuse, and they include pattern burns made with household appliances or cigarettes, and scalds, often due to tap water.

Other Traumatic Injuries and Mimickers of Child Abuse

Using the hair to grab the child or pulling a child's hair may result in alopecia in children. Acute scalp tenderness may be present at the site of the pulled hair roots. Petechiae over the head and neck can be a result of neck compression associated with strangulation.

The number of mimickers of child abuse is high, but dermatologists are trained to differentiate. Just because a child has a condition that mimics abuse, it doesn't mean they are not a victim of abuse.

Some common mimickers of child abuse include Mongolian spots, leukemia, and hemophilia for bruising. A Vitamin K deficiency can also lead to unexplained bruising. Mimickers for burns include contact dermatitis, bullous impetigo, and car seat or seat belt buckle burn. Moreover, it has been reported that accidental laxative ingestion may lead to symptoms that mimic abusive burns.

Dermatologists have a legal obligation to report any suspicions of abuse, but this does not automatically mean that the child in question has been indeed subjected to physical abuse. The dermatologist's report needs to be consistent with history and other evidence, so it's imperative that dermatologists are aware of this when differentiating.