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Differential diagnosis of suspected child physical abuse: Skin manifestations

Differential diagnosis of suspected child physical abuse: Skin manifestations
Author:
Stephen C Boos, MD, FAAP
Section Editors:
Daniel M Lindberg, MD
Jan E Drutz, MD
Deputy Editor:
James F Wiley, II, MD, MPH
Literature review current through: Apr 2025. | This topic last updated: Sep 26, 2024.

INTRODUCTION — 

The differential diagnosis of conditions that may be mistaken for child abuse with cutaneous findings is presented here. The differential diagnosis for conditions that may increase the risk of fractures is discussed separately. (See "Differential diagnosis of suspected child physical abuse: Orthopedic manifestations".)

The clinical manifestations of child abuse, the diagnostic evaluation for suspected child abuse, and the differential diagnosis of abusive head trauma are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Differential diagnosis'.)

DIAGNOSTIC APPROACH — 

When evaluating a child in whom physical abuse is suspected, the clinician should remember that cutaneous findings that appear to be abusive may result from other causes. The major considerations include:

Unintentional injury – A careful history and physical examination can often reassure the clinician that the cutaneous injury is unintentional. By contrast, specific features of bruising or burns can be characteristic of an abusive injury (figure 1). In these patients, a plausible history is typically lacking (table 1). (See "Physical child abuse: Recognition", section on 'Inflicted bruises'.)

Medical conditions – Skin manifestations of some medical conditions may mimic bruising, burns, or cause ecchymosis due to an underlying bleeding disorder. A helpful distinguishing feature between children with abusive injuries and those with underlying medical conditions is that many abused children present with multiple types of injuries (eg, bruising and fractures) (table 2). Identifying multiple types of injuries decreases the likelihood that a single medical entity has produced all of the findings, although certain conditions (eg, osteogenesis imperfecta, Ehlers-Danlos syndrome, or congenital insensitivity to pain) provide exceptions to this rule. (See 'Conditions with skin and multisystem manifestations' below.)

Cultural practices – Many cultures use various means to mark the skin in order to treat various illnesses and conditions. They include cupping, coining, spooning, moxibustion, and salting [1-4]. While some cultural practices, such as female genital cutting, are generally considered to be abusive in resource-abundant countries, the practices described in this topic have not been reported to cause harm to the child and in fact, demonstrate efforts to improve the child's health. They should not be considered as a form of abuse. However, because cultural practices may be administered instead of bringing children to effective medical care, their use may contribute to medical neglect.

Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate arrival at the correct diagnosis, initiation of appropriate therapy, and avoidance of the consequences of an unnecessary evaluation for and/or report of suspected child abuse.

However, the diagnosis of a cutaneous mimic of child abuse does not exclude the possibility that physical abuse has occurred. The full clinical picture including all historical features and physical findings must be assessed when abuse is suspected. Although studies of children evaluated for child abuse suggest a low frequency of cutaneous mimics in these patients, a significant minority of children have findings of both [5,6]. For example, of almost 3000 children evaluated for physical abuse, approximately 5 percent had a cutaneous mimic (eg, dermal melanosis, impetigo, and bruising due to a bleeding disorder) [5]. Six percent of children with cutaneous mimics still had "high concern" for child abuse when the full picture was considered.

The medical literature contains many assertions of medical conditions being confused for abuse that are incompletely documented or speculative. Sometimes these assertions are challenged, and other times not [7-10]. Ultimately, a clinician must consider the relative likelihoods of all potential conditions alongside the possibility that a child with a medical condition may, in addition, be abused [11].

The recognition and diagnostic evaluation for physical child abuse are discussed in greater detail separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

BRUISES

Differential diagnosis — Bruises are the most common type of injury in abused children [12]. However, unintentional traumatic bruising is also common once infants are cruising or walking. (See "Physical child abuse: Recognition", section on 'Inflicted bruises'.)

Besides abusive and nonabusive traumatic bruising (including the cultural practice of "coining" or "spooning"), the differential diagnosis of bruising also includes a number of medical disorders:

Dermal melanosis (formerly Mongolian spots)

Hemangiomas

Striae

Delayed subaponeurotic fluid mass

Immunoglobulin A vasculitis (Henoch-Schönlein purpura) and other vasculitides

Bleeding disorders (eg, hemophilia and other factor deficiencies, thrombocytopenias, disseminated intravascular coagulopathy, von Willebrand disease, platelet function disorders, and Vitamin K deficiency)

Skin staining (eg, blue clothing dye transfer to the skin)

These conditions and the features that help distinguish them from abusive bruising are discussed below.

Nonabusive traumatic bruising in healthy children

Unintentional bruising — Bruising is the most common form of both unintentional and abusive injury. The age of the child and the nature, shape, location, distribution, number, and size of bruises can be used to raise or lower the suspicion for abuse. Bruising is uncommon among healthy infants younger than six months of age who have not been abused. This finding contrasts with observed rates of bruising of up to 50 percent of infants who are cruising or crawling. The majority of walking children have bruises.

The most common locations of unintentional bruises include the scalp, knee, shin, or thigh, though other areas, particularly the back, forearms, nose, or cheek, are sometimes injured in mobile infants and children. Premobile infants seldom have more than one bruise, and crawlers and cruisers seldom more than two, but walkers commonly had five or more bruises. The majority of walking children have bruises, which are typically multiple. During validation of the TEN-4-FACES-P clinical prediction rule, common areas of bruising in children under four years old included the lower leg (64 percent), knee (34 percent), forehead (27 percent), upper leg (12 percent), lower arm (8 percent), orbital rim, and zygoma (8 percent each) [13]. In a cross-sectional study of children 0 to 13 years, bruise locations associated with eight common accidental injury mechanisms consisted of the shin, knee, forehead, and elbow [14].

By contrast, the following bruising characteristics should raise suspicion for child abuse (see "Physical child abuse: Recognition", section on 'Inflicted bruises'):

Any bruising in infants younger than six months of age

More than one bruise in a premobile infant and more than two bruises in a crawling child

Bruises located on the torso, ear, neck, or buttocks

Bruises with a pattern of the striking object (figure 1) (eg, slap, belt, or loop marks (picture 1); spoons; spatulas; or other objects)

Human bite marks (see "Physical child abuse: Recognition", section on 'Inflicted bruises')

Medical conditions mistaken for bruising

Dermal melanosis (formerly Mongolian spots) — Dermal melanosis, previously referred to as Mongolian spots, are common bluish-green areas of skin discoloration often seen in African American, Hispanic, or Asian infants. While typically described as disappearing by one year, many persist, sometimes into adulthood. They are seen most commonly on the buttocks and lower back, but may extend over the entire back and on extremities (picture 2). Acutely they may be distinguished by their characteristic coloring and location and their persistence for months to years will clearly differentiate them from bruising [15]. Nevi and hemangiomas occasionally may create similar confusion and are distinguished in a similar manner. Preliminary evidence suggests that transcutaneous bilirubin testing may be helpful to differentiate bruising (measured value elevated compared with adjacent native skin) from dermal melanosis (measured value same as adjacent native skin) without requiring extended follow-up [16]. (See "Skin lesions in the newborn and infant", section on 'Dermal melanocytosis'.)

Hemangiomas — Hemangiomas are congenital malformations of vascular tissue forming a benign tumor (picture 3 and picture 4). They are most commonly recognized under the surface of the skin, where their appearance depends on their depth. Hemangiomas have occasionally been mistaken for bruises and reported as child abuse [17,18]. Additionally, hemangiomas may rarely cause coagulopathy through consumption of platelets and circulating clotting factors in the Kasabach-Merritt syndrome. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications" and "Infantile hemangiomas: Evaluation and diagnosis".)

Striae — Striae are linear streaks of depressed, thin appearing skin that may have red or purple color. Striae atrophicae are a normal finding of adolescence, primarily on the lumbar area. Striae distensae are a normal finding of skin distended during pregnancy and obesity, primarily occurring on the abdomen, flanks, buttocks or thighs. Striae have been mistaken for acute bruises or scars, and may give the impression of the child having been whipped with a cord [19-23]. (See "Striae distensae (stretch marks)".)

Delayed subaponeurotic fluid mass — Subaponeurotic fluid mass is rare condition presenting as fluid filled masses on the scalp of infants up to 18 weeks of age that may cross suture lines [24,25]. Medical providers may be unfamiliar with the condition, and as a result, 13 percent of parents or caregivers described questioning about possible child abuse [26]. Subaponeurotic fluid collections should be distinguished from subgaleal hemorrhage. (See "Neonatal birth injuries", section on 'Subgaleal hemorrhage'.)

Neuroblastoma — Neuroblastoma may present with periorbital edema and ecchymosis, suggesting orbital impact or basilar skull fracture [27,28]. In one case report, a 2-year-old presented deceased with initial suspicion of abuse and autopsy diagnosis of neuroblastoma [29].

Medical conditions that predispose to bruising

Bleeding disorders — Bleeding disorders mistaken for child abuse include factor VII, VIII and IX deficiencies, von Willebrand disease, immune thrombocytopenia (ITP), platelet function abnormalities, and thrombocytopenia caused by leukemia or other myelodysplasias [15,30-32]. Multiple chromosomal and nonchromosomal congenital syndromes are associated with thrombocytopenia [33].

Fewer than 3 percent of premobile infants (ie, young infants who are not yet rolling over) with bleeding disorders have a bruise, and fewer than 10 percent of infants who are rolling over and who have bleeding disorders have a bruise. The most common location for these bruises are the knees, shins, forehead, and nose. Once children walk, bruises are more numerous, and a wider distribution is seen. Bruising of the ears, neck, genitals and hands are unusual at all ages, and bruising of the buttocks and anterior trunk is rare in premobile infants. About 15 percent of children with hemophilias present in a way that may be confused with abuse. Only half of these children have a family history of a named bleeding disorder. While excess nonpatterned bruising, or "fingertip" bruising may be seen, a more developed patterned bruise has not been described in these children. A minority of these children present with more serious bleeding, such as intracranial hemorrhage. (See "Approach to the child with bleeding symptoms".)

Some secondary bleeding disorders including disseminated intravascular coagulation, and liver failure may result from trauma or create bleeding that mimics trauma. (See "Disseminated intravascular coagulation in infants and children".)

For children who do not receive vitamin K at birth (often home births, alternative medicine, or in less developed health care environments), bleeding from vitamin K deficiency most commonly occurs in the first three months of life with bleeding from mucosal surfaces, prior incisions such as circumcisions, cutaneous bruising, and deeper muscle bruising [30,34]. Rarely, vitamin K deficiency occurs in children with malabsorption of fat soluble vitamins (eg, cystic fibrosis or liver disease). (See "Overview of vitamin K", section on 'Predisposing conditions'.)

When laboratory abnormalities are identified, consultation with a hematologist who has pediatric expertise is encouraged before ordering more advanced testing.

The evaluation for a coagulation disorder is part of the diagnostic evaluation for child abuse and is discussed separately. (See "Physical child abuse: Diagnostic evaluation and management", section on 'Evaluation for bleeding disorders'.)

IgA vasculitis — Children who have immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]), acute hemorrhagic edema of childhood (AHEC), acute hemorrhagic edema of infancy (AHEI), and other vasculitides have purpuric lesions caused by breakdown of the capillary walls. These lesions may appear diffusely on the body in areas not typically associated with bruising from normal activities (eg, shins) and can be mistaken for child abuse [35,36]. The diagnosis of vasculitis is often suggested by the initial appearance (eg, palpable purpura), accompanying features, such as abdominal pain, joint pain, and/or hematuria in patients with IgAV (HSP), and when new bruises continue to develop under clinical supervision. (See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis".)

Cultural practices associated with bruising — Some cultural practices (eg, coining or spooning) performed with good intent result in patterned bruises (picture 5) or bruises on the neck, face, and back include:

Coining — Coining is used in Southeast Asian cultures to treat fever, headache, and chills [37,38]. In Vietnamese, this process is referred to as "cao gio" or "scratch the wind" since it is thought to release illness-causing "bad winds" from the body [39,40]. Oiled skin is rubbed firmly with the edge of a coin, producing multiple, symmetric linear red marks, usually on the back (picture 5). Serious complications, including severe burns that required skin grafting when the oil on the skin caught fire, have been reported, but this is generally a benign procedure that should not be considered maltreatment [40].

Spooning — Spooning ("qua sha") is similar to coining and is used in China to rid the body of the evil spirits that are thought to cause illness. In this procedure, wet skin is rubbed with a porcelain spoon, producing multiple linear, and symmetric ecchymoses [15,39].

Skin staining — In our experience, staining of the skin (eg, transfer of dye by blue clothing) has sometimes been mistaken for bruising. The superficial appearance of the mark, lack of tenderness, and the uniformity of color suggest skin staining as the likely cause. Wiping with alcohol or soap and water may remove the mark, or at least demonstrate transfer of the dye to the wipe and makes the diagnosis.

BURNS

Differential diagnosis — In addition to abusive and nonabusive burns (including cultural practices such as cupping or moxibustion), the differential diagnosis of burns includes an assortment of dermatological conditions:

Infections: Impetigo and Staphylococcal scalded skin syndrome

Dermatitis of various forms

Bullous conditions (congenital and acquired)

Nonabusive burns

Unintentional burns — The primary differential diagnosis for abusive burns is unintentional burns. Because the mechanism of burns (eg, contact with a hot object or liquid) is the same regardless of intent, a complete history of how the burn happened and a full examination of the skin is necessary before identifying a burn as unintentional. In addition, even if the burn is unintended, the clinician must consider whether the burn occurred because of caregiver neglect.

Unintentional burns have a plausible history and an expected burn pattern. For example, unintentional hot fluid (scald) burns commonly occur due to spills and involve the hand, forearm, shoulder, face, and upper chest. They are usually unilateral and in a pattern, consistent with contact from flowing water down the body or splashes of hot liquid.

Evaluations of tap-water burns are best coordinated with an agency, typically the regional fire department, that will go to the home, replicate the given history, and measure the temperature of any water at the tap. This approach permits a given history to be validated. Because tap water scalds indicate that a hot water heater is set above recommended temperatures, possibly in violation of building codes, reporting to public health or housing authority officials may prevent future injuries. (See "Epidemiology, risk factors, and prevention of burn injuries", section on 'Scald prevention'.)

The characteristics of intentional burns and differentiation from unintentional burns are discussed in detail separately. (See "Physical child abuse: Recognition", section on 'Intentional burns'.)

Chemical and irritant burns — Exposure to a wide range of chemicals may create destructive lesions of the skin that can be mistaken for thermal or inflicted injury [41]. Most such burns come from common household cleaning products. Bleach has been singled out because it is readily available and initial exposure may be nonpainful [42].

Cases of desquamating perianal rash may occur from exposure to diarrhea. This finding may occur with prolonged exposure but has, in particular, been reported following ingestion of senna alkaloid-based laxatives [43,44]. These burns occur in diapered children and can closely mimic the pattern of an inflicted immersion burn but typically do not extend beyond the diaper area. History, particularly of exposure to senna-based laxatives, is usually elicited.

Medical conditions mistaken for burns

Impetigo — Impetigo is a skin infection usually caused by staphylococci or streptococci that can look similar to a cigarette burn (picture 6). Impetigo involves only the superficial layers of the skin; the lesions are flat, crusted, and heal cleanly. In contrast, inflicted cigarette burns penetrate more deeply (usually full-thickness), have heaped-up margins, and heal with scarring [15]. (See "Impetigo".)

Staphylococcal scalded skin syndrome (SSSS) — SSSS is a desquamating condition caused by systemic distribution of exfoliative toxin secreted by a focal infection with Staphylococcus aureus (picture 7). Misdiagnosis with scald burn has occurred when the infection is not recognized [45]. Evolution of the condition under observation and identification of the infecting organism establish the diagnosis. (See "Staphylococcal scalded skin syndrome".)

Dermatitis — A 2024 systematic review of the literature identified 23 reported cases of dermatitis initially diagnosed as child abuse [46]. Lesions were mistaken for burns or welts and were attributed to phytophotodermatitis [12], irritant contact dermatitis [47], allergic contact dermatitis [6], and one each of atopic dermatitis and streptococcal perianal dermatitis (picture 8).

Phytophotodermatitis is a burn-like skin lesion that occurs when sunlight interacts with photosensitizing compounds (eg, bergamot, psoralen) found in certain fruits, vegetables, or fragrance products; limes are most common, but lemons, figs, parsnips, and celery also have been implicated (table 3) [15,48,49]. The burn-like lesions are characterized by erythema and bullae, often in unusual patterns corresponding to the contact (streaks from dripping juice, handprints from adults handling the sensitizing material and then handling the child) or around the hands and mouth after the child handles or ingests the agent (picture 9). The eruption typically appears hours to days after exposure, which can make the lesion more difficult to relate to the contact [15,48].

Bullous conditions — Both congenital and acquired dermatological conditions causing bullae and desquamation have rarely been reported as causing initial concern for child abuse by burning. SSS is mentioned above.

Epidermolysis bullosa is a family of rare diseases leading to bullae and desquamation following mild or unrecognized skin trauma (picture 10). Erythema multiforme is an inflammatory condition, often with viral precursor, producing typical target lesions with dusky centers that sometimes vesiculate. Both have been reported as mistaken for abuse [50,51]. (See "Epidermolysis bullosa: Epidemiology, pathogenesis, classification, and clinical features" and "Erythema multiforme: Pathogenesis, clinical features, and diagnosis".)

Cultural practices associated with burns

Cupping — In cupping, the air in an open-mouthed vessel is heated by various means, and then the vessel is applied to the skin. The suction force created by the cooling and contracting of the heated air is thought to "draw out" the ailment. The heated air and the rim of the cup burn the skin. This technique is used in many cultures [15,39]. Cupping presents as multiple, grouped circular ecchymoses, usually on the back. Central ecchymosis or petechiae result from the suction effect of the heated air as it cools and contracts (picture 11).

Moxibustion — Moxibustion is the therapeutic burning of pieces of moxa herb (mugwort or Artemisia vulgaris) or yarn on the skin. It is used in Southeast Asia, where it is considered a form of acupuncture. The lesions of moxibustion appear as a pattern of small discrete circular burns and may be confused with cigarette burns (picture 12) [15,39,52].

Salting — Salting (application of salt to the skin or packing in salt) is a traditional Turkish custom that is thought to improve the health of a newborn's skin. A case of epidermolysis, severe hypernatremia, and death in a 30-day-old infant who had been intermittently salted since birth has been reported [53].

Garlic poultice application — Garlic poultice application to the skin of infants as a naturopathic remedy has been reported to cause bullae and partial-thickness burns [54,55]. Additional culture-specific complementary and alternative therapies that may cause irritant hyper- or hypo-pigmentation, blisters, or burns to the skin are discussed below.

CONDITIONS WITH SKIN AND MULTISYSTEM MANIFESTATIONS — 

Multisystem manifestations suggestive of trauma (eg, fractures, subdural hematomas, and retinal hemorrhages) without an explanatory history increases the chance of child abuse. Conditions that may be confused with bruising and multisystem trauma are rare but include osteogenesis imperfecta (OI), Ehlers-Danlos syndrome, and congenital insensitivity to pain.

Osteogenesis imperfecta — Children with OI have manifested other findings that may raise concern for child abuse. Easy bruising is often mentioned in reviews of OI, and OI patients have altered coagulation and skin biomechanics [56]. Subdural and retinal hemorrhages have also been reported in children with OI [57]. Though the picture is not typical of classic acute abusive head trauma, these children may be confused with milder presentations of abusive head trauma. The skeletal manifestations of OI are discussed in greater detail separately. (See "Differential diagnosis of suspected child physical abuse: Orthopedic manifestations", section on 'Osteogenesis imperfecta' and "Osteogenesis imperfecta: An overview".)

Ehlers-Danlos syndrome — Ehlers-Danlos syndrome (EDS) is a common family of connective tissue and collagen disorders with highly variable presentation. Common forms of EDS produce easily bruised and injured skin, with a velvety texture, hyper-distensibility (picture 13), and unusual papyraceous scarring (picture 14). Some forms of EDS create increased joint mobility that predisposes to orthopedic problems in older mobile children (picture 15). Rarer forms of EDS cause fragility of large blood vessels and internal organs and may present with internal injuries following relatively mild trauma. Such a situation might be expected to cause concern for child abuse.

Claims that EDS causes confusion with abusive fractures has been asserted in the courtroom [58]. Other than an overlap form of EDS with OI, which demonstrates mutations in the Col 1A1 and Col 1A2 genes, EDS is not known to lead to fracture in infancy and should not be used as an alternative etiology during evaluation for possible child abuse [58]. In one longitudinal study of orthopedic records of patients with EDS, the prevalence of fractures did not appear to be elevated relative to normal children [59,60]. As noted above, these children are older, but the rate is not significantly elevated above the incidence of fracture in the healthy population. In another retrospective case-control study that evaluated 21 individuals with genetically or criterion-based diagnosis of EDS beginning in infancy and compared with 63 matched controls, EDS patients had significantly more fractures during childhood (odds ratio [OR] 3.4 [95% CI 1.2 to 9.7]) [61]. However, no EDS patient had a fracture during the first year of life, and a minority of them sustained more than a single fracture. (See "Ehlers-Danlos syndromes: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Laboratory evaluation for EDS in children depends upon findings. Hypermobile type EDS is the most common variant but lacks a laboratory marker and has significant overlap with normal childhood flexibility. Elevated bleeding scores are reported in 56 percent of hypermobile EDS children, and easy bruising in 36 percent [62]. Because diagnosis is by Beighton scoring, which cannot be reliably performed in young children, bruising in infants with hypermobile EDS has not been explored. About 50 percent of adults with hypermobile EDS have elevated bleeding scores [63]. More serious internal bleeding, including intracranial bleeding and rupture of viscera, is known to occur in vascular type EDS, also known as type IV, and associated with mutations in the COL 3A1 gene. These rarely occur in other EDS subtypes [64]. (See "Ehlers-Danlos syndromes: Clinical manifestations and diagnosis", section on 'Genetics and pathogenesis' and "Ehlers-Danlos syndromes: Clinical manifestations and diagnosis", section on 'Hypermobile EDS'.)

Congenital insensitivity to pain — Hereditary sensory autonomic neuropathies are a rare group of disorders of the peripheral nerves in which the victim is unable to sense pain and often temperature, whereas all other sensation (light touch, deep touch, proprioception) remains intact. (See "Hereditary sensory and autonomic neuropathies".)

These disorders may be inherited in an autosomal dominant or recessive fashion or may be sporadic. Because of the lack of pain and/or temperature sensation, injuries and secondary infections are common occurrences. Injuries include bruises, burns, lacerations, fractures, and bite wounds (often self-inflicted because of the lack of pain, resulting in mutilation or amputation of the lips or fingertips). The wounds typically are undetected by caretakers because of the lack of complaint from the child. If the wounds remain open, they may become infected, leading to bacteremia, osteomyelitis, and other sequelae. (See "Hereditary sensory and autonomic neuropathies".)

Plain radiographs may demonstrate multiple fractures of varying ages, and residual deformities from undetected and unset fractures are common occurrences. Even fractures that are diagnosed and immobilized may heal poorly because of continued weight-bearing on the affected limb [65]. The fracture patterns may be similar to those seen in intentional injury. In contrast to the radiographic findings in the severe forms of OI, the bones are of normal density. (See "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)

The diagnosis of congenital insensitivity to pain can be made by taking a careful history and performing a thorough neurologic evaluation that includes pain and temperature testing. Sensory nerve conduction velocity is slowed or absent, and nerve biopsy may reveal a decrease in myelination or fewer unmyelinated fibers than normal. One type (type 4, congenital insensitivity to pain and anhidrosis) involves recurrent unexplained episodes of hyperpyrexia in infancy caused by the absence of sweating. Anhidrosis may be secondary to the lack of innervation of the eccrine sweat glands. (See "Hereditary sensory and autonomic neuropathies".)

BRUISING DURING RESUSCITATION — 

Trauma, and thus child abuse, should be considered in any child requiring unexpected resuscitation or resuscitation for a previously unknown condition. Resuscitation itself, however, is a well-recognized cause of traumatic injury. As an example, in one observational study of 226 infants younger than one year of age who were resuscitated and died, external injuries on the face, neck, and chest were seen in 12 percent of patients (21 with abrasions and 6 with contusions) [66]. However, fingernail abrasions, petechiae, or fingertip contusions were rare, regardless of whether resuscitation occurred or not. Contusions were more common in homicide (child abuse) victims. Another study of 51 newborns, infants, and toddlers found at least one injury in 27.5 percent [67]. Most injuries are cutaneous, though superficial contusion of internal organs is sometimes seen.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Child abuse and neglect".)

SUMMARY AND RECOMMENDATIONS

Diagnostic approach – The presence of a condition that mimics child abuse does not exclude the possibility that abuse has occurred. The full clinical picture including all historical features and physical findings must be assessed when abuse is suspected. The differential diagnosis of suspected child abuse in children with cutaneous manifestations consists of a variety of conditions. Major considerations include (see 'Diagnostic approach' above):

Unintentional bruises or burns

Medical conditions that mimic or cause bruises or burns

Cultural practices

Familiarity with the medical conditions or cultural practices that mimic child abuse can facilitate:

Arrival at the correct diagnosis

Initiation of appropriate therapy

Avoidance of the consequences of an unnecessary evaluation and/or report of suspected child abuse

The presence of multiple types of injuries (eg, bruising, fractures, and intracranial injury) suggests abuse (table 2) because conditions that mimic abuse typically only have skin findings (eg, bruising or burn/blistering) with the exception of a limited number of systemic conditions (eg, Ehlers-Danlos syndrome, osteogenesis imperfecta [rare], or congenital insensitivity to pain [rare]).

Bruises – The most common conditions mistaken for inflicted bruising in children consist of nonabusive traumatic bruising including cultural practices such as coining (picture 5) or spooning, undiagnosed bleeding disorders, vasculitis, dermal melanoses (formerly Mongolian spots (picture 2)), and hemangiomas (picture 3 and picture 4). (See 'Medical conditions mistaken for bruising' above.)

Burns – Because the mechanism of burns (eg, contact with a hot object or liquid) is the same regardless of intent, a complete history of how the burn happened and a full examination of the skin is necessary before identifying a burn as unintentional. In addition, even if the burn is unintended, the clinician must consider whether the burn occurred because of caregiver neglect. (See 'Unintentional burns' above.)

Lesions that appear like burns may arise from phytophotodermatitis (picture 8), impetigo (picture 6), bleach exposure, diarrhea caused by senna laxatives, or cultural practices such as cupping or moxibustion (picture 11 and picture 12). (See 'Burns' above.)

Conditions with multisystem manifestations – Bruising combined with other multisystem manifestations suggestive of trauma (eg, fractures, subdural hematomas, and retinal hemorrhages) without an explanatory history increases the chance of child abuse. Conditions that may be confused with multisystem trauma are rare but include osteogenesis imperfecta, Ehlers-Danlos syndrome, and congenital insensitivity to pain. (See 'Conditions with skin and multisystem manifestations' above.)

Bruising during resuscitation – Although resuscitation is associated with bruising in children, child abuse should be considered in any child requiring unexpected resuscitation or resuscitation for a previously unknown condition. (See 'Bruising during resuscitation' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Erin Endom, MD, who contributed to earlier versions of this topic review.

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