Cutaneous mimics of abuse

1. Cutaneous mimics of abuse Maryanne Lobo VFPMS

2. 90% of victims of physical abuse present with skin manifestations • Evidence of psycho social problems frequently introduces a bias towards diagnosis of abuse • Under diagnosis of abuse has catastrophic consequences for the child • Over diagnosis - catastrophic consequences for parents/family

3. Mandatory reporting – non abusive skin conditions may be reported due to • Ignorance • Rare conditions • Uncommon presentations of common conditions

4. Case 1 • 3 children, new migrants, all noted to have multiple round, linear and geometric pigmented lesions and scars on face, extensor arms/forearms and dorsum of hands. • Teachers worried they are cigarette burns as children report that their parents beat them • One child presents with blistering rash after a visit to the beach in summer.

5. Hepatoerythropoietic porphyria mistaken as child abuse • AR • Photodistribution of rash • Blistering erosions and scarring/hyperpigmentation • Facial hypertrichosis • Neonatal thrombocytopenia • Chronic haemolytic anaemia • Brownish urine, hepatosplenomegaly, discoloured teeth • Developmental delay • Polyarthritis

6. Genetic disorders Ehler Danlos syndrome

7. Incontinentia pigmenti: in 6 d female with seizures, hyperpigmented lesions and bruises, maternal grandmother known to CPS. Mum single 18 yr old.Cerebral infarcts, cerebral oedema and scant RH

8. Case 26 mo old referred by MCHN for tender bruises on toes

9. Pernio or chilblains 12-24 hr after exposure to non freezing cold and damp Single/multiple, red purplish, oedematous lesions, turn yellowish brown, with desquamation Intense pain, burning, itching Toes/fingers, dorsum of proximal phalanges, pinnae, cheeks, thighs Circulation normal Excessive cold, neglect, low BMI: anorexia nervosa, presence of cryoproteins, SLE, presence of anticardiolipin/antiphospholipid antibodies

10. Popsicle panniculitisAunt had given him popsicles to help with teething painBenign cold induced subcutaneous fat necrosis on cheeks of young infantsOccurs 1-3 days after cold exposureLocalised, indurated nodules, ill defined margins, cold, and painfulSelf limiting disorder, symptomatic relief The Atlas of Emergency Medicine

11. Case 3Chid care workers report this 9 mo old with bruises to face, ears and forearm

12. Acute haemorrhagic oedema of infancy 4-24 mo Follows URI, vaccinations, antibiotics Systemically well -low grade fever Non tender, asymmetric, cockade (rosette), annular/targetoid purpura and oedema Face, ears and limbs, less common scrotum and umbilicus (Cullen sign mimic) Rare visceral and joint involvement Recurrences, resolves in 2-3 weeks

13. HSP mistaken for child abuse

14. Hypersensitivity/Vasculitis Erythema nodosum • Idiopathic, infections (TB, strep, mycoplasma), systemic (sarcoid, IBD), drugs ( sulphas, OC) • In children infection is most common cause • >in females • Panniculitis-inflammation of SC fat • Smooth, red, painful nodules, 2-6 cm, coalesce, continue to appear for 3-6 w • Anterior surface of legs, thighs, and forearms • Fever, arthralgia may occur • As it heals may become yellowish and look like bruises may desquamate • Infection - heal in 7 w may last up to 18 w, idiopathic - last 6 mo

15. Hypersensitivity/Vasculitis Urticarial vasculitis • Eruption associated with burning pain • Generalized/localized wheals or plaques with central clearing • Petechiae within lesion and resolve with bruises or post inflammatory hyperpigmentation • Lasts> 24 hr in a fixed location unlike urticaria which migrates in minutes to hours • Photosensitivity, arthralgia, angioedema, fever, dyspnoea, abdominal pain, pleural/pericardial effusions • Most idiopathic • Drugs: penicillin, sulphas, fluoxetine, NSAID • Autoimmune disease SLE, Sjogren’s • Malignancies • Infections: Hep B, Hep C, IM

16. Case 4 Mother tell child care worker that this 2 yr old has a cough and is on Amoxycillin When changing his nappy this lesion is noted When asked how he got it the boy says “burn” CP notified

17. Fixed drug eruptions (FDEs) • Start as few, sharply demarcated, erythematous, macules • Rapidly become erythematous plaques • Commonly on the lips, genitalia, and trunk. • Lesions heal with hyperpigmentation • Occur in the same site with re-administration of the responsible drug • In 30% of cases, macules become vesicles and bullae, may lead to a more severe reaction known as generalized bullous FDE resembling SJS-TEN.

18. Case 54 mo old FTT, mother know to have substance abuse, states these lesions developed in a few hours, GP suspects burns?

19. Staphylococcal scalded skin syndrome

20. Skin infections that mimic burns Erysipelas Bullous impetigo

21. Skin infections that mimic cigarette burns Ecthyma Impetigo

22. Case 66 yr old sees new GP for itchy vagina, Mother tells GP the perineal defect has always been present, but GP refers for sexual abuse assessment

23. Perineal failure of midline fusion • Can be misdiagnosed as sexual abuse • Failure of midline fusion occurs along the perineal midline between the vagina/scrotum and anus can result in mucosal exposure • Typically resolves at puberty. • Accurate documentation of the finding is important to avoid misdiagnosis of child sexual abuse. • If unsure regarding the defect, examine the child twice at 2-week intervals to note if the defect changes. A change in the defect in a 2-week period would indicate that it is not failure of midline fusion but rather an acute, possibly traumatic, defect.

24. Case 7Separated parents-hostile relationship, returned from access with mother with a swollen toe.

25. Hair tourniquet • Hair tourniquet is not uncommon in babies • To be differentiated from intentional banding • Pseudo -Ainhum-from congenital constricting bands • (Ainhum-idiopathic fibrotic band develops after minor trauma, common in tropics, leads to autoamputation)

26. Ainhum vs Pseudoainhum Amniotic constriction bands

27. Case 8 9 yr old presents to GP with itchy sore genitalia GP knows that mother has a new boyfriend who has assaulted the mother Reports to CP

28. Ano-genital lichen sclerosus • Can be mistaken for sexual abuse. • 10% - 15% of all cases occur in prepubertal children, with girls > boys 10 to 1 • Benign but chronic condition of the skin characterized by ivory or white shiny macules and papules that form hypopigmented plaques • A figure-eight pattern often is present encircling the vulva and anus. The hymen typically is spared. • The skin becomes thin and fragile and may fissure, bruise, excoriate, and bleed easily. Purpura may be present. • Typical symptoms of ano-genital lichen sclerosus include itching, bleeding, and hemorrhagic blisters; hence the confusion with sexual abuse. • May be associated with considerable dysuria and/or pain on defecation, which can result in holding of urine and bowels leading to nocturnal enuresis, encopresis, and sleep disturbances. These behaviours can raise concerns for sexual abuse.

29. Case 910 yr old returns from access with his father with a red sore bottom?

30. Perianal streptococcal dermatitis • Superficial infection of the perianal area that can involve the external genital area • Caused by group A β-hemolytic streptococci. • Symptoms include perianal erythema with mostly well-defined margins, perianal swelling, oozing/anal discharge, pruritus, pain, painful defecation, anal fissures, and blood on stools or anal bleeding • Perianal streptococcal dermatitis can be mistaken for sexual abuse because of its associated symptoms. • Diagnosis is made by bacterial culture of the affected area, optimally from oozing areas. • Treatment involves topical antibiotic treatment with mupirocin or erythromycin, or more frequently, oral penicillin V. • Perianal streptococcal dermatitis is not sexually transmitted

31. Case 10

32. Genital infections that may mimic sexual abuse Molluscum contagiosum

33. Case 11 7 yr old returns from access with her father with vaginal bleeding and pain Mother reports to CP

34. Urethral prolapse • Presents with vaginal bleeding and swelling • May be misdiagnosed as sexual abuse • Typically occurs in young (Black) girls, between ages of 4 and 8 years • Occurs when the urethra mucosa evaginates beyond the urethra meatus, resulting in vascular congestion and oedema of the prolapsed tissue • Factors contributing to urethral prolapse include oestrogen deficiency, large weight for age, trauma, urinary tract infection, and anatomical defects. • Can be medically managed by Sitz baths and oestrogen cream; if symptoms are severe or persist, referral to a urologist may be necessary.

35. Case 1212 yr old presented with vulval ulcers, preceded by fever, sore throat and mylagias. GP did HSV PCR which was negative

36. Vulvar aphthous ulcers • Range 10–19 yrs • Minor (<1 cm), major (>1 cm), herpetiform-multiple, small, clustered • Common site was within the vestibule but occasionally found on the keratinizing epithelial surfaces of labia majora and perineum. (This is in marked distinction to oral aphthae, which are never found on the perioral skin of the face.) • 50% report oral lesions • One-third develop recurrences of vulvar ulcers.

37. Causes for non ST anogenital ulcers • Aphthous ulcers (aphthosis, canker sores, Lipschutz ulcers, ulcus vulvae acutum) • Infections HSV via autoinoculation, EBV, CMV, VZV, Group A Strep, Mycoplasma, Molluscum contagiosum • Autoimmune Crohn's disease, Behçet's disease (Aphthous genital ulcers that last for weeks and heal with scarring), Vaculitis (Lupus). Pemphigus and Pemphigoid (lesions may mimic lichen sclerosus with extensive scarring) • Drug reactions Fixed drug eruptions, Stevens Johnson's syndrome/ toxic epidermal necrolysis • Other Erosive Lichen Sclerosus, Hair removal folliculitis, Epidermolysis bullosa, Allergic contact dermatitis 

38. Case 13 This 2 w baby (of Turkish background) is brought in with seizures and large areas of blistering rash. Electrolytes reveals Na of 165 mmol/L. What could have caused this presentation?

39. Cultural practices - salting • Application of salt to skin-Turkish custom to improve complexion • Can result in epidermolysis (looks like burns) and hypernatremia

40. Cultural practices Spooning Coining

41. Cultural practices Moxibustion Cupping

42. Case 14First day in child care referred to CP as burns? dermatlas.med.jhmi.edu

43. Birthmarks • Ulcerated haemangioma • Haemangioma and stork marks have been mistaken for bruises and pinch marks caused by abuse

44. Birthmarks: Perianal verrucous epidermal naevus Seen at birth, but may be delayed up to puberty Close set warty papules coalesce to keratotic plaques-linear distribution In perianal area may mimic viral warts Stable nature, linear distribution and HPE can be used to differentiate The Journal of Paediatrics 2009 154: 306

45. Birthmarks: Congenital dermal melanocytosis • > 90% SE Asians, 80 % other Asians Africans, 50-70% Hispanics, < 10% in whites • May appear after birth in first few weeks • Fade by 3yr, may persist longer • Looks like bruises to the untrained eye • No swelling or tenderness • Unchanged over days

46. Case 15A teacher is worried about these recurrent red marks on this boy. They fade after a few days to brown bruise like lesions. Do you want a clue? What are these lesions?What is a diagnostic sign? emedicine.medscape.com

47. Cutaneous mastocytosis • Any number, any size, yellow tan to red brown • Asymptomatic or pruritic macules, papules, nodules, plaques, • May blister or become bullous on exposure to sun • More on trunk than limbs, spares face, scalp, palms and soles • Darier sign - surrounding wheal and erythema on rubbing • Systemic symptoms - flushing, headache, dyspnoea, rhinorrhoea, wheezing, vomiting, diarrhoea, syncope- exposure to certain drugs or foods • 75% occur in infancy and childhood and resolve by puberty

48. Neuroblastoma • Most common extracranial solid tumour of childhood • 2/3rds have metastatic disease on presentation • Presentation with periorbital ecchymosis with or without proptosis (from orbital metastasis) may mimic abuse • Bone metastasis is multiple symmetric and metaphyseal • CT brain can show necrosis, haemorrhage and calcification • Urine catecholamines-VMA and HVA

49. Perianal Langerhans Cells Histiocytosis • Child with Perianal red indurated lesions referred for sexual abuse exam. Swab does not grow Streptococcus pyogenes.

50. Case 16This child who has substantiated Hx of neglect has patchy hair loss. Hairs easily plucked. Is it traumatic alopecia? What else could it be?