Annular scars with hyperpigmentation

The case

A hospital’s emergency department (ED) requested that a dermatologist evaluate an 18-month-old girl who has ringed scars with hyperpigmentation on the right side of her buttocks and back (Figure). The child was referred to the ED by her primary care provider (PCP), who first noted the skin findings during a well-child visit.

Figure

Diagnosis: Lamp cord beating scars

The child was accompanied by her mother, who reportedly had not noticed the lesions until the PCP inquired about them. Later, in the ED, the mother stated that the child lies against the crib bars, which leave markings on her skin. The history revealed no other concerning signs or symptoms, and the child was in no acute distress. A careful physical examination revealed multiple discrete, annular scars with hyperpigmentation and well-demarcated borders on the right side of the child’s back and buttocks. There was no surrounding erythema, ecchymosis, or edema. Remaining physical exam findings were unremarkable.

During the initial evaluation, the history of the crib bars as the mechanism of injury was deemed inconsistent with the skin findings. The patterned scars were suspicious for child abuse. A report was made to child protective services (CPS), and the child was evaluated in the ED by the child maltreatment team.

Possible signs of abuse

CPS agencies investigate more than 2 million reports of alleged child maltreatment each year in the United States.¹ In 2019, approximately 656,000 children were substantiated as victims of abuse and neglect, roughly 18% of whom endured physical abuse.¹ Child neglect and abuse is the fourth leading cause of death for children between 1 and 4 years of age.² National statistics on physical abuse represent only cases investigated and substantiated by state CPS agencies. The true prevalence is likely higher, based on hospitalization rates for physical abuse and adult reports of childhood physical abuse from other entities.^3,4 The COVID-19 pandemic has caused loss of income and increased social isolation, both of which exacerbate the risk of child maltreatment.⁴

Recent data reveal a decline in both official reports to CPS agencies and the number of ED visits related to maltreatment, but the percentage of hospitalizations for child abuse and neglect rose from the previous year.⁴ This trend in data may be attributed to decreased in-person contact between children and mandated reporters, as well as a shift in health care–seeking patterns during the COVID-19 pandemic and the resulting decline in the total number of ED visits.⁴ These concerning findings suggest that the severity of child abuse injuries has remained the same or worsened.⁴

The law requires that injuries that are suspicious for neglect or abuse be reported to state CPS agencies. The Child Abuse Prevention and Treatment Act defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “an act or failure to act which presents an imminent risk of serious harm.”¹ This federal legislation provides a foundation for identifying child maltreatment, but each state has its own definition of child abuse and neglect that influences the recognition and reporting of child physical abuse.^1,3 Personal and cultural experiences also influence recognition and reporting.³

Child physical abuse can result in permanently disfiguring injuries.³ Children who experience physical abuse are at greater risk of developing behavioral problems including conduct disorders, aggression, and depression.³ Victims of child physical abuse are more likely to begin use of tobacco and drugs as adolescents and report chronic physical and mental health diseases as adults.³

There are many factors related to the parent, child, and environment that increase the risk of child physical abuse. Infants and toddlers are most vulnerable.^1,3 Children cared for by a single parent; parent(s) of young age; or parent(s) with a personal history of abuse as a child, substance and/or alcohol use, or depression are at higher risk of physical abuse.³

Child physical abuse often goes unrecognized until it results in severe injury or death.⁵ Recognizing and diagnosing physical abuse can be challenging. Physical abuse typically occurs between the perpetrator and the child without a witness present. Perpetrators rarely admit to their actions, and child victims are often preverbal or too fearful to disclose the abuse.³ Sentinel injuries—minor inflicted injuries identified by physicians or caretakers prior to recognizing the child as a victim of physical abuse—are common in abused infants but are sometimes underappreciated and not reported.³

Child physical abuse may be suspected based on inconsistent history and suggestive physical examination findings. Specific skin injuries that may suggest physical abuse include patterned bruising, laceration, abrasions, and scars, particularly in the shape of a handprint, stick, cord, or belt.^3,5,6 Other possible signs: symmetrically distributed lesions; multiple lesions at different stages of healing; and lesions on areas protected by clothing; any injury to a nonmobile infant; and severe, unexplained injuries.^3,5,6

Differential diagnoses

When child abuse is suspected, it is critical to consider a broad differential because many skin conditions mimic physical abuse injuries.^7-9 The arched form of certain annular lesions may resemble lesions that result from cable or cord beatings.⁸ For this case, the differential included tinea corporis, erythema annulare centrifugum, erythema marginatum, and urticarial viral exanthems.

Tinea corporis, a fungal infection, causes lesions that appear on the trunk or extremities and are characterized by slightly red, annular, well-demarcated, scaly patches, often with central clearing.^10,11 Tinea corporis lesions can be differentiated by their pruritic nature and variable size.¹⁰

Erythema annulare centrifugum, a reactive skin condition with lesions that also appear on the trunk or extremities, is characterized by red, annular, or arcuate patches or plaques with central clearing.¹¹ However, erythema annulare centrifugum can be differentiated by trailing scales and advancing margins.¹¹

Erythema marginatum often occurs with acute rheumatic fever, particularly in patients with acute carditis; it is characterized by transient, pink or slightly red, well-demarcated, and somewhat elongated annular lesions with central clearing.⁷ These lesions can be differentiated by their disappearing and reappearing character and the presence of systemic symptoms of acute rheumatic fever.^7,8 Urticaria multiforme is a viral exanthem characterized by red macules and plaques, typically along with a fever.¹² Polymorphic distribution, serpiginous edges, and associated systemic symptoms differentiate lesions of urticarial viral exanthems.¹²

This case’s differential also included folk remedies such as cupping and coining. In some cultures, these practices are performed on children for healing and protection and can produce transient patterned skin markings that may be misdiagnosed as physical abuse injuries.⁹ Thorough history taking and cultural considerations can help differentiate these lesions. In this case, these causes were ruled out by the lack of history with these practices.

Required reporting

As stated earlier, when a history and/or physical examination prompts reasonable suspicion for physical abuse, pediatric providers are mandated by law to make a report to local CPS agencies.³ Mandatory reporting laws do not require freedom of doubt of physical abuse, and states must provide immunity from prosecution even if the reported allegations cannot be substantiated as child abuse or neglect.^3,13 However, failure to make a report can result in civil action or criminal charges against the provider or, worse, additional injury or death of the child.³

In this particular case, the child was admitted to the hospital overnight and placed in foster care by CPS while the evaluation was completed, which was the appropriate action to safeguard the patient. It is the hope of these authors that having a heightened understanding of what determines child abuse will lead to more vigilance in protecting our pediatric populations.

References

1. US Department of Health and Human Services. Child maltreatment 2019. Published January 14, 2021. Accessed February 28, 2021. https://www.acf.hhs.gov/cb/report/child-maltreatment-2019

2. Leading causes of death reports, 1981-2019. Centers for Disease Control and Prevention., Accessed February 28, 2021. https://wisqars.cdc.gov/fatal-leading

3. Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-e1354. doi:10.1542/peds.2015-0356

4. Swedo E, Idaikkadar N, Leemis, R, et al. Trends in US emergency department visits related to suspected or confirmed child abuse and neglect among children and adolescents aged <18 years before and during the COVID-19 pandemic: United States, January 2019: September 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1841–1847. doi:10.15585/mmwr.mm6949a1

5. Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013;88(10):669-675.

6. National Institute for Health and Care Excellence (Great Britain). (2017). Child maltreatment: when to suspect maltreatment in under 18s. National Institute for Health and Care Excellence. Published July 22, 2009. Accessed February 28, 2021. https://www.nice.org.uk/guidance/cg89/resources/child-maltreatment-when-to-suspect-maltreatment-in-under-18s-pdf-975697287109

7. Chakravarty SD, Zabriskie JB, Gibofsky A. Acute rheumatic fever and streptococci: the quintessential pathogenic trigger of autoimmunity. Clinical rheumatology. 2014;33(7):893-901. doi:10.1007/s10067-014-2698-8

8. Gondim RM, Muñoz DR, Petri V. Child abuse: skin markers and differential diagnosis. An Bras Dermatol. 2011;86:527-536. doi: 10.1590/s0365-05962011000300015

9. Pomeranz ES. (2018). Child abuse and conditions that mimic it. Pediatr Clin North Am, 2018;65(6):1135-50. doi:10.1016/j.pcl.2018.07.009

10. Ely JW, Rosenfeld S, Stone MS. Diagnosis and management of tinea infections. Am Fam Physician. 2014;90(10):702-710.

11. Wei-Li K, Tsai, HH. Generalized annular skin lesions. Am Fam Physician. 2013;87(7):513-514.

12. Schaefer P. Acute and chronic urticaria: evaluation and treatment. Am Fam Physician. 2017;95(11):717-724.

13. Child Welfare Information Gateway. Immunity for reporters of child abuse and neglect. Accessed March 7, 2021. https://www.childwelfare.gov/pubPDFs/immunity.pdf