Chapter 106. Skin Signs of Physical Abuse

Child abuse is an uncomfortable topic for most practitioners and is a source of anxiety, anger, and confusion among those who care for children. True incidence statistics are difficult to determine, but each year in the United States, of the approximately three million children referred to child protective services, approximately one million are determined to be the victims of abuse and neglect (or about 12 cases per 1,000 children) and approximately 1,500 die from abuse or neglect.1 Clearly, those whose practices involve the dermatologic care of children encounter real or suspected child abuse. Practitioners must have some basic knowledge of abuse and its evaluation to appropriately manage these cases.

Because many forms of physical abuse have external manifestations, the skin examination may serve as the first clue that abuse is taking place. Conversely, a broad knowledge of skin diseases provides a unique insight into those diagnoses that may mimic various forms of child abuse (Tables 106-1 and 106-2). The literature is rich in examples in which an astute clinician averted the disastrous results of a false claim of abuse by correctly diagnosing a dermatologic condition.

True abuse must be reported and a thorough evaluation conducted. It is essential that practitioners develop a relationship with the institution or individual in their area who is best able to manage these difficult cases. Ideally there should be an abuse team consisting of a dermatologist, pediatrician, social worker, medical photographer, and, when needed, pediatric subspecialists such as orthopedists, hematologists, psychologists, and gynecologists. The need for specialization in this field is highlighted by the institution in the United States of pediatric subspecialty board certification in child abuse, beginning in 2010. It is most helpful if one's relationship is forged with the abuse team before an abuse incident and a set protocol for dealing with alleged or suspected abuse is established in the practitioner's office. Local emergency phone numbers for reporting abuse can be obtained from the Child Welfare Information Gateway or Childhelp National Headquarters (Table 106-3).

Child abuse spans all ages with 32% of abused children being younger that 4 years of age, 24% being 4–7 years of age, and 19% being 8–11 years of age. Typical children who suffer abuse have emotional or behavioral problems, have special medical needs, have several siblings, live in single-parent households, or live at or below the poverty level. Abuse is approximately two times more common in Pacific Islanders, American Indians, Native Alaskans, and African American children compared to the average American population. Perpetrators tend to have emotional or psychological problems, have frequently been victims of abuse themselves, abuse drugs or alcohol, are perpetrators of spousal abuse or have a history of marital discord, have marginal parental skills or knowledge, and have poor self-esteem. Parents are the perpetrator 80% of the time.2 Although these profiles are helpful, it is important to remember that any child may be the victim of abuse.

The Battered Child

Bruising is the result of blunt trauma, delivered either accidentally or intentionally. Active children, particularly toddlers, are prone to multiple bruises, and the identification of abusive injury is fraught with difficulty. The size, shape, color, and feel of a bruise varies on the basis of anatomic site, the degree of force used, the firmness of the object delivering the force, and the underlying health of the injured individual. Great care and attention to detail must be exercised when evaluating these children who likely have been brought to the office for some other complaint. The history should include as much detail as possible and inconsistencies in the parent's story clearly documented in the medical record (eTable 106-3.1).3 It is essential to perform a total body, skin, and mucous membrane examination. It is also important to note the child's behavior and parent–child interactions.

The color of all bruises should be noted and clearly documented. This may aid in determining the age of a bruise and may point out inconsistencies in the caretaker's history. Multiple bruises of differing colors may indicate ongoing trauma rather than one isolated incident. Caution must be exercised in dogmatically, stating the time of injury based on bruise characteristics because color depends on the intensity, depth, and location of the injury. There is good evidence that a bruise with any yellow color must be older than 18 hours, but a bruise may be red, blue, or purple/black throughout its life span, from beginning to resolution. Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate.4 It is most prudent to document color without alluding to a specific age of a bruise in the medical record. Faint bruised might be more easily visualized with the use of a Wood's lamp.

Although there are no absolute differentiating features, certain aspects of an intentionally inflicted bruise may suggest abuse. Because young children tend to explore in a forward direction, accidents are more frequent on the distal arms and legs, knees, elbows, and forehead. Soft, padded, posterior, and protected areas of the body are far less likely to be accidentally injured. Bruises on the abdomen, buttocks (Fig. 106-1), thighs, genitalia, ear lobes, and cheeks are uncommon, so marks in these areas should raise concern.

Inflicted bruises often leave patterned imprints of a hand, whip, or hard object. Linear purpura, with a small triangle at the base (Fig. 106-2) representing the interdigital and finger web spaces, occurs after a slap injury. Grab or pinch marks can be recognized by their location on soft padded areas and their unusual patterning. Circumferential purpura or hemosiderin pigmentation (Fig. 106-3) suggests a ligature injury, which would be difficult to explain as accidental. Bite marks (Fig. 106-4) are always inflicted, although they are sometimes from siblings or other children. The shape and size of the marks can identify an adult mouth versus a bite from a child. It is helpful to include a ruled measuring scale in any photographs to help forensic identification at a later date.

The head is the most common target of physical abuse (see eFig. 106-4.1). Black eyes are common accidental injuries but are more suspicious if they are bilateral or are unaccompanied by evidence of trauma to the nose or superior orbital ridge. Subconjunctival hemorrhages can be seen in 0.5%–13.0% of typical newborns, but a large subconjunctival hemorrhage beyond 1 and 2 weeks of life is suspicious of abuse. Petechiae in the periorbital region have been seen in children with abuse related retinal hemorrhages. Accidental bruising or other injuries to the oral mucous membranes are unusual and should be considered as suspect (see eFig. 106-4.2).

Any bruises in a young infant who is not yet pulling to a stand should raise concerns of abuse or of an unsafe environment (see eFig. 106-4.3). A shaken infant may have bruising on the hands because he or she is liable to be flailing during the shaking incident (see eFig. 106-4.4). Concern should be raised whenever the history of an accident is inconsistent with the developmental level of the child.

Inflicted Burns

The most common agent involved in childhood burns, both accidental and inflicted, is hot liquid. Accidents such as inadvertently stepping into a hot tub or pulling a hot liquid off a table counter or stove leave irregular or geographic burn patterns that lack symmetry. By contrast, inflicted scalds tend to be symmetric, with sharply demarcated edges and an absence or paucity of splash marks. In one study, all the children whose bathtub burns were inflicted had associated features of abuse, including bruises, fractures, or evidence of neglect.5 Stocking and glove burns result when the feet or hands are forcibly held under hot water. The uniformity of the burn indicates that the child was not able to reflexively withdraw from the scalding water as would happen with accidental immersion. A common pattern of inflicted immersion burn involves the buttocks, low back, and thighs. The child is flexed at the waist and dipped into the hot water, frequently as a punishment for a toilet training accident. The resultant pattern may give “zebra stripes” on the abdomen due to sparing of the flexural skin that is protected from the scald when bent forward. A “donut hole” pattern of sparing might be seen on the buttock if the child is pushed forcibly to the bottom of the tub that is cooler than the scalding water.6 Inflicted splash burns are much more difficult to differentiate from accidents. A careful history is needed to detect inconsistencies between the proposed injury and the physical examination. When doubt exists, it is mandatory that child protective services be contacted.

An inflicted contact burn can be recognized by the pattern that duplicates the object creating the injury (see eFig. 106-4.5). Accidental contact burns tend to be smaller, less severe, less patterned, and of irregular depth. When a child is held against a hot object, the depth is more uniform, the pattern is more clearly defined, and the burn is more severe. Irons, curling irons, hot plates, and cigarettes are objects commonly used to inflict burns.7 Some burns may, in fact, be accidental but represent inadequate supervision and neglect. This situation is also harmful to children and needs to be reported to the appropriate agencies.

Sexual Abuse

It is estimated that more than 300,000 children suffer from sexual abuse each year in the United States. The lifetime risk of sexual abuse is approximately 25%–40% for girls and approximately 10% for males. Sexual abuse is defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared, and cannot give informed consent and violate the social taboos of society.8 This broad definition includes inappropriate touching, genital penetration, fondling, and sexual kissing, but also includes noncontact activities such as exhibitionism, voyeurism, and the involvement of a child in verbal sexual propositions or the making of pornographic pictures or movies. Clearly, many forms of sexual abuse leave no physical examination findings.

Girls are more likely than boys to suffer sexual abuse and the risk rises in preadolescence (Fig. 106-5). Most abuse is at the hands of someone known to the child and only 10% is carried out by strangers. Victims and perpetrators span all racial, religious, and socio-economic spectrums but risk factors for sexual abuse include the presence of a stepfather, single-parent families, children whose mothers are extensively out of the home, a history of parental violence, parents who have suffered abuse themselves, parental substance abuse, and low household income level.

Most victims of sexual abuse have no physical findings.9,10 Pregnancy, positive cultures for sexually transmitted diseases, presence of sperm or acid phosphatase, acute genital or anal injuries without plausible explanation, and marked hymeneal opening enlargement with associated hymeneal disruption are very definitive signs of abuse. However, it is very seldom that such signs are present. The American Academy of Pediatrics Committee on Child Abuse and Neglect recommends that certain findings are consistent with, but not diagnostic of, abuse. These include chafing, abrasions or bruising of the inner thighs and genitalia, scarring, tears or distortion of the hymen, a decreased amount or absent hymeneal tissue, scarring of the fossa navicularis, injury to or scarring of the posterior fourchette, scarring or tears of the labia minora, and enlargement of the hymeneal opening, even without disruption of the hymen.8

The child's spoken word is the most valuable piece of evidence in establishing sexual abuse. All historical information must be very well documented and preserved with the same care as any piece of forensic evidence. It is immensely important to enlist the help of an experienced abuse team in obtaining the history and completing an appropriately thorough physical examination with the aid of colposcopic observations.

The skin examination's greatest contribution may be in correctly diagnosing those dermatoses that may look similar to sexual abuse but are not. Irritant dermatitis, atopic dermatitis, psoriasis, seborrheic dermatitis, pinworms, candidiasis, scabies, and other common dermatoses tend to cluster in the diaper region and should be easily diagnosed with a critical eye. Other conditions that have been reported as mimickers of sexual abuse are listed in Table 106-4.

Genital warts pose a particularly difficult problem for practitioners. They certainly can be sexually transmitted to children, and the possibility of sexual abuse needs to be discussed with parents. However, there is much evidence that genital warts can be acquired perinatally from an infected mother, through autoinoculation from warts on other parts of the body or through nonsexual contact with caretakers.11 Children younger than 3 years of age at the onset of warts are least likely to have acquired their warts from sexual contact, whereas children with onset after 5 years of age have a much greater risk of having suffered sexual abuse. The ages in between represent a gray zone. Other signs of abuse will seldom be present to aid in the diagnosis, and human papillomavirus typing is not helpful. History provides the most valuable insight into the correct diagnosis; again, it is imperative that an abuse team be involved. At the author's institution, all children with perianal or genital warts are referred, in a nonaccusatory and nonjudgmental fashion, to the hospital's abuse social worker and pediatrician as routine protocol.12

Elder abuse is one of the fastest growing forms of abuse. Although statistics vary, the National Center on Elder Abuse in Washington, DC, estimates that 1 to 2 million Americans 65 years of age or older are victims of various forms of abuse each year. Abuse may affect a range of 2%–10% of the elderly population. Those older than age 80 years are two to three times more likely to suffer abuse, and the American population in this age range continues to increase each year. For every case of reported elder abuse, at least another five cases go undetected.13 All segments of society are affected. Although there is inherent inaccuracy in these statistics, it is readily apparent that elder abuse is common enough for a busy dermatologist to encounter a few abused patients every week.

The US National Academy of Sciences has defined elder abuse as:

(a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm.

Acts of commission and omission are thus included in the definition. Types of abuse and their respective incidence rates are listed in Table 106-5. More than one type of abuse can occur simultaneously.14,15

Abuse most often occurs at the hands of caregivers or family members who have frequent close contact with patients and often may live with them. Historically, adult children of the abused patient have been the most common perpetrators, but most recent data show that spouses now account for the majority of abuse cases. Men are more likely to abuse than women. The abuser is often financially dependent on the victim, and they are usually in a shared living situation. However, financial abuse is more common among those who live alone. Risk factors for abuse are listed in Table 106-6. Note that the risk factors have far more to do with the caretaker than the abused patient. In particular, the level of debility or health status of the patient does not predict abuse.

Physical abuse is defined as the intentional application of any force that causes bodily injury, pain, or impairment to an elderly individual. It may include acts such as hitting, beating, shaking, kicking, slapping, pushing, pinching, burning, overly aggressive force-feeding, and the improper use of physical or chemical restraints. The signs discussed in Section “Child Abuse” above apply to elder abuse as well and include multiple bruises or fractures in different stages of healing, bruises in normally well-protected areas such as the inner thighs, odd-shaped injuries such as from pinching or slapping, belt marks or patterned bruising (see eFig. 106-5.1), unusual welts or puncture wounds, cigarette burns, rope marks that might indicate restraints, bed sores, strangely patterned alopecia, attempts to hide part of the body, and signs of malnutrition or dehydration. Because many of these signs, particularly multiple bruises, can occur normally in elderly individuals, detection of abuse can be very challenging. Unexplained repetitive injuries or explanations by caretakers that do not match the pattern of injury are concerning. Caretakers who act withdrawn, infantilize the patient, or insist on providing the medical history should alert the clinician.

It is important to interview by directing questions to the patient rather than the caregiver, and it is prudent to try to arrange a time to confer with and examine the patient alone. Repetitive follow-up visits help develop a rapport with the patient and allow serial observation of past and ongoing injuries. The assurance of confidentiality facilitates garnering sensitive information.

Once abuse is suspected, most states mandate that physicians contact the appropriate authorities. Information on a particular state's laws can be obtained from the National Center on Elder Abuse (see Table 106-3). The nearest medical center's social service department is well equipped to offer guidance, but the agencies listed in Table 106-3 are also helpful resources. Treatment, support, and counseling may be needed for the perpetrator as well.

Domestic violence is a pattern of coercive behaviors that may include repeated battering, psychological abuse, sexual abuse, social isolation, deprivation, and intimidation perpetrated by someone who is or was involved in an intimate relationship with the victim. Conservative estimates say that in the United States approximately 1 million people suffer domestic violence each year, but the actual number likely approaches 4 million. Women comprise approximately 90%–95% of all victims, and men 95% of all perpetrators. Forty percent to 60% of men who abuse their partner or spouse are also abusing their children. In the United States, approximately one in three women suffers a least one physical assault during her life, and 1,500 women are murdered by their husbands or boyfriends each year.16,17 Domestic violence is a devastatingly common problem.

The profiles of domestic abuse are similar to child and elder abuse. Women ages 19–29 years are the most common victims, with other risk factors being low income, mental health issues, alcohol or substance abuse by the victim or the perpetrator, pregnancy, large age difference between partners, separated or divorced status, and a family history or personal past history of abuse and violence. Women with educational or occupational levels above that of their partners may be at higher risk. Abusers are typically underachievers with occupational status below their educational level.16,17

Whenever possible, the patient should be interviewed alone, without the partner's presence. A thorough examination should be done with a nurse chaperone, but not the partner, in the room. Repeat visits may be used to document new or progressing skin findings and to build trust with the patient. Statements such as “Because domestic violence is such a prevalent problem, we have begun to ask about it routinely” may open the door to more discussion regarding difficulties at home. Literature and posters in the clinic setting with information and hotline numbers for abuse victims indicate the common reality of abuse and may facilitate disclosures.

For various reasons, a victim may not want to reveal abuse. Implausible explanations for an injury or a delay in seeking medical attention may be clues of abuse. Signs of depression, excessive use of sedatives, chronic pain disorders, or vague stress-related symptoms may be subtle signs of abuse.17

Physical examination findings are the same as outlined for child and elder abuse. The distribution of injuries tends to be central, and the perpetrator may choose to injure hidden areas, such as the breast or genitals, to deter detection. Unlike infants or debilitated adults, blows to a young adult may be to areas suggesting a defensive posture and might include purpura, sprains, dislocations, and fractures to the wrist or forearms, palms, and soles.

The social service department at the local medical center is a good resource for information and help on domestic violence. The National Domestic Violence hotline (800–799-7233) is a 24-hour resource for women who need to find a local shelter. Other helpful organizations can be contacted (see Table 106-3).