Mongolian spots (also referred to as blue-gray macule of infancy) are the most frequently encountered birthmarks in neonates. Melanin-containing melanocytes in the dermis are present (migrational arrest) and the distinctive blue color, characteristic of dermal melanin, occurs as a result of the Tyndall effect (when light strikes the surface of the lesion, red wavelengths of light are absorbed and blue wavelengths are reflected back from the brown melanin pigment from the dermis). More than 95% of African American and 80% of Asian infants are born with Mongolian spots. The skin lesion is flat (macular), slate-gray, bluish-gray or brown, and consists of poorly circumscribed, single or multiple lesions ranging in size from a few millimeters to several centimeters. The most common location is the sacrum and buttocks (90%), but lesions may occur anywhere, including the back, shoulders, or flank. Mongolian spots fade gradually and are resolved by age 5 to 6 in about 96% of cases. Differential diagnosis of Mongolian spots includes accidental or inflicted injury and other forms of dermal melanocytosis (eg, nevus of Ito or Ota).
Mongolian spots do not lead to any symptoms and require no treatment. Family needs to be reassured about the benign nature of these lesions.
Mongolian spots can be mistaken for ecchymosis resulting from inflicted injuries. Mongolian spots are nontender unlike ecchymosis, which may be tender.
An ecchymotic skin lesion undergoes sequential color changes and resolves within a few days, whereas Mongolian spots do not undergo similar color changes and fade spontaneously over a period of years.
Figure 2.3 ▪ Mongolian Spot.
An infant brought to the ED in cardiopulmonary arrest had these lesions thought to be Mongolian spots; however, inflicted bruises from child abuse were in the differential diagnosis. The medical examiner would typically incise areas of skin discoloration to exclude underlying contusions from inflicted injuries. (Photo contributor: Binita R. Shah, MD.)
Folk healing practices are used by various cultures to treat illness. Coin rubbing (also known as Cao Gio, scratch the wind, or coining) is practiced among Southeast Asians (Vietnamese and Cambodians) when a child is sick. Warm oil (eg, tiger balm or mentholated oil) is applied over the affected region of the body, and then it is vigorously rubbed in with the edge of a coin. This is an attempt to rid the body of “ill wind” to reduce fever and chills. Cupping (ventosa) is used in some Eastern European, Latin American, and Russian cultures to reduce congestions. Alcohol is applied to the inner rim of the cupping glass and ignited with cotton soaked in alcohol. The cup is applied to the skin after the flame is extinguished. As it cools, a vacuum forms in the cup causing an ecchymotic lesion at the site. Spooning (spoon rubbing or quat sha) is used among the Chinese to relieve pain and headache. The skin is scratched with a porcelain spoon until ecchymotic lesions appear. Moxibustion is also practiced among the Chinese. It is a form of acupuncture. Burning sticks of incense, yarn, cigarettes, or cones of the herb Artemisia are used to make small circular burns on the skin at therapeutic points. Maquas is used by Arabs, Jews, and Bedouins. Hot metal spits or coals are applied to areas of disease or over a traditional “draining point” to produce burns. Caida de mollera (fallen fontanelle) is used by Mexicans and Hispanics. An attempt is made to elevate the fontanelle in infants who are dehydrated by holding the infant upside-down. Retinal hemorrhages may be seen with this practice and it resembles shaken impact syndrome.
Figure 2.4 ▪ Coin Rubbing (Cao Gio).
Linear, bilateral, and symmetrical lines of purpura in the intercostal spaces in a Cambodian boy produced by rubbing with a hot coin in an effort to cure fever. (Coin Rubbing (Cao Gio). From American Academy of Pediatrics: The C. Henry Kempe National Center on Child Abuse and Neglect. American Academy of Pediatrics, Elk Grove Village, IL, 1994, p.12.)
These practices are not followed to injure the child, but rather are performed with the belief that they will help the child heal or recover from an illness. Ignorance of these folk healing practices on part of the medical team results in allegations of physical abuse, and trust between the medical team and the family may be irrevocably damaged. Consultation with a child abuse specialist may help in difficult cases. Educate parents about the injurious nature of these practices and suggest alternative approaches to treating illness.
Figure 2.5 ▪ Coin Rubbing (Cao Gio).
This Cambodian boy with linear patterns of petechiae and purpura on the neck was referred to the ED by the school nurse to “rule out” child abuse. The common sites in coin rubbing are along bony prominences and include spine, neck, and intercostal spaces. (Photo contributor: Binita R. Shah, MD.)
Folk healing practices (also known as pseudo-battering) may be mistaken for inflicted injuries from child abuse.
Physicians should become familiar with folk healing practices in their community.
Figure 2.6 ▪ Cupping (Ventosa).
(A) Several round identical purpuric lesions are seen on the back because of cupping that was used to relieve back pain. First- or second-degree burns may also be seen in cupping. The common sites are back, abdomen, and chest. (B) Close-up of purpura produced by cupping. (Photo contributor: Binita R. Shah, MD.)
Figure 2.7 ▪ Inflicted Child Abuse Bruises. Differential Diagnosis of Cupping and Coin Rubbing.
(A) Belt buckle mark from inflicted injury. (B) Close-up of belt buckle mark. Geometric shapes or patterns to bruises suggest child abuse. (C) Bruises inconsistent with the stated history or multiple bruises in different stages of healing (suggestive of repeated abuse), unusual locations (eg, genitalia, buttocks, neck) suggest child abuse. (Photo contributor: Binita R. Shah, MD.)
Cold panniculitis is an inflammation of subcutaneous fat after prolonged exposure to cold or prolonged application of a cold object to any area of the skin (eg, ice packs applied to the face of an infant to control supraventricular tachycardia or ice packs applied to the lower extremities after vaccination). It is believed to occur solely because of the inherent properties of infant body fat with a higher percentage of saturated fatty acids (compared with older children and adults) and an increased propensity to solidify with prolonged exposure to a cold object. The degree of fat necrosis is inversely related to the age of the patient. Popsicle panniculitis is caused by sucking on ice, seen especially in infants who while sucking on the popsicles or ice cubes do not move them around in the mouth (as done by adults) keeping the cold object in contact with buccal fat for a prolonged period.
Figure 2.8 ▪ Cold Panniculitis.
(A) An infant was referred to “rule out” child abuse when this erythematous and indurated lesion near the corner of the mouth was seen during a well baby visit. It was thought to be a red bruise produced by pinching. A history of sucking on an ice cube 2 days prior to appearance of this lesion was subsequently obtained. (Photo contributor: Binita R. Shah, MD.) (B) Bilateral erythematous, indurated lesions adjoining each side of the mouth after sucking on a popsicle. (Reproduced with permission from: Shah BR, Laude T: Atlas of Pediatric Clinical Diagnosis. WB Saunders, Philadelphia, 2000, p. 176.)
Figure 2.9 ▪ Cold Panniculitis versus Buccal Cellulitis.
(A) An afebrile, very playful infant with an erythematous, indurated, and mildly tender lesion on the cheek was admitted with a diagnosis of child abuse versus buccal cellulites. A history of putting ice packs on his cheeks because of an extreme heat wave 2 days prior to appearance of the rash was obtained subsequently. (B) Erythematous, indurated, and tense swelling with severe tenderness was seen in this highly febrile and irritable child. Blood culture was positive for Streptococcus pneumoniae. (Photo contributor: Binita R. Shah, MD.)
Figure 2.10 ▪ Cold Panniculitis.
(A) A young infant presented with an erythematous, indurated, linear “skin rash,” thought to be a bruise inflicted by a long object (eg, a ruler or belt), and the family was referred to child protective services. The mother said that her 6-year-old son was eating a popsicle (like that shown in Figure 2.10B), and had placed the popsicle on the thigh of the infant. A skin biopsy confirmed the diagnosis of cold panniculitis, and charges were subsequently dropped against the family. (Photo contributor: Binita R. Shah, MD.)
Popsicle panniculitis is commonly seen in the summer. Typically there are no systemic signs like fever or leukocytosis. The skin lesion is red to purplish indurated, discrete nodules or plaques with mild tenderness and sometimes itching. Lesions are seen in the perioral area (adjacent to the corners of the mouth) and may be unilateral or bilateral. Panniculitis lesions resolve spontaneously in 2 to 3 weeks without scarring. Differential diagnosis includes child abuse, subcutaneous fat necrosis from other etiology (eg, hypercalcemia, trauma), buccal cellulites, giant urticaria, contact dermatitis, or frostbite.
Cold panniculitis is self-limiting and does not require specific therapy except reassuring caregivers. Recurrence is common and parents must be educated about the condition. Dermatology consultation and a skin biopsy (nonspecific lobular adipocyte necrosis at the dermal–epidermal junction with a surrounding mixed inflammatory infiltrate seen) may aid in doubtful cases.
A history of skin exposure to a cold object followed by a skin lesion supports the diagnosis of cold panniculitis. (Important: Panniculitis arises within hours to 1 to 2 days after the exposure to a cold object).
Popsicle panniculitis lesions due to sucking on ice are seen adjacent to the corners of the infant’s mouth.
Nevus of Ota and Ito arise from dermal melanocytes and are present at birth in about 50% of cases. A second peak occurs during puberty. The skin lesion is a light to dark brown, blue-black, or bluish-gray macule with a mottled or specked appearance. It increases in intensity and size with time and persists for life. They are more common in Asians (about 75% of cases; most commonly found in the Japanese), in African Americans, and in girls. Nevi of Ota occur on the face, forehead, zygomatic region, periorbital area, cheek, nose, or eye. Ipsilateral eye involvement (ocular melanosis) is commonly seen in moderate to severe cases and may involve the sclera (most common), conjunctiva, cornea, iris, retina, and optic nerve. Other mucous membranes and tissues (ear canal, tympanic membrane, pharynx, hard palate, nasal mucosa, buccal mucosa) may be rarely involved. Nevi of Ito occur on the supraclavicular region, shoulder, upper arm, and neck. Differential diagnosis of these nevi includes postinflammatory hyperpigmentation, café-au-lait spot, or Mongolian spots.
The diagnosis is made by typical clinical appearance. These nevi do not require any intervention in the ED. Patient can be referred to a dermatologist for evaluation and therapies that may include laser surgery or masking with cosmetics. If ocular melanosis is present, glaucoma may occur (melanocytes in the ciliary body of the anterior chamber may impede normal flow of fluid), and patients also need periodic funduscopic examinations by an ophthalmologist.
Nevi of Ota and Ito may be mistaken for ecchymoses due to inflicted child abuse injuries. However, these nevi are nontender unlike ecchymoses, which may be tender.
An ecchymotic lesion undergoes sequential color changes and resolves within a few days. These nevi do not undergo similar color changes and are permanent lesions.
These nevi are unilateral, present in a specific anatomic location and have a speckled or mottled appearance unlike Mongolian spots, which are uniform in appearance and fades spontaneously over the years.
Figure 2.12 ▪ Nevus of Ota versus Inflicted Bruise from Child Abuse.
(A) Close-up of patient (Figure 2.11) showing blue-gray pigmentation with a specked appearance and involvement of the sclera. (B) Bluish and red areas of discolorations are seen around the eye of a patient who was punched in both eyes by her stepmother. She also had subconjunctival hemorrhage in her other eye and numerous bruises in different stages of healing. (Photo contributor: Binita R. Shah, MD.)
A port-wine stain (PWS), also known as nevus flammeus, is a congenital vascular malformation of dermal capillaries present at birth. Most commonly they are seen on the face or neck but may occur anywhere. The lesion is pink to purple, varied in size and shape, and sharply circumscribed. Large lesions follow a dermatomal distribution and rarely cross the midline. During infancy and childhood the lesion is macular; as age increases, it may become darker in color, papular or nodular, causing disfigurement. Elevated skin lesions may bleed spontaneously.
PWS may occur as an isolated birthmark (majority of patients) or be associated with a syndrome, including Sturge-Weber syndrome (PWS in the distribution of the V1-V2 branch of the trigeminal nerve, intracranial calcifications, seizures, glaucoma, etc) and Klippel-Trenaunay syndrome (PWS over an extremity, hemangiomas, varicosities, and limb hypertrophy of the involved extremity). Differential diagnosis of PWS includes capillary hemangioma and other vascular malformations (eg, salmon patch).
Figure 2.14 ▪ Port-Wine Stain.
Pink-purple macular lesions on the buttocks led to referral of this infant to the ED to “rule out” child abuse. These lesions were present since birth. Location of these lesions can mimic abuse as one of the typical sites for inflicted bruises are buttocks and lower back. (Photo contributor: Binita R. Shah, MD.)
PWS is diagnosed clinically and does not require any intervention in the ED. Refer the patient to a dermatologist for evaluation for laser therapy. Radiologic studies (as clinically indicated) may be ordered to evaluate patients with Sturge-Weber syndrome presenting to the ED with seizures and may include CT scan and/or MRI. Such patients will need appropriate referrals to neurologist and ophthalmologist.
Figure 2.15 ▪ Port-Wine Stain.
Most common location of PWS is the face. It may be confused with a red or purple bruise inflicted by abuse, especially when it is very extensive as shown. When a PWS is localized to the trigeminal area of the face (especially around the eyelids), a diagnosis of Sturge-Weber syndrome must be considered. (Photo contributor: Binita R. Shah, MD.)
PWS can be confused with inflicted bruises from child abuse.
An ecchymotic skin lesion undergoes sequential color changes and resolves within a few days. PWS does not undergo similar color changes; however, PWS may become darker in color and more nodular over the years.
PWS does not regress spontaneously and persists for a lifetime.
Figure 2.16 ▪ Port-Wine Stain; Klippel-Trenaunay Syndrome (KTS).
PWS on the foot and extending onto the leg and thigh in an infant with KTS. (A, B). PWS associated with hemihypertrophy of the extremity in a child with KTS. Skin discoloration and “swollen” (hypertrophied) extremity may be mistaken for inflicted injuries (C). (Photo contributors: Sharon A. Glick, MD [A, B] and Binita R. Shah, MD [C].)
Phytophotodermatitis (PPD) is an acute phototoxic eruption following contact with certain plants, fruits, or vegetables containing photosensitizing compounds and exposure to sunlight. Examples of plants causing phototoxic reactions include limes, lemons, celery, parsnip, fig, fennel, parsley, dill, mangoes, carrots, and meadow grass. PPD occurs only with contact with a photosensitizing furocoumarin (psoralens) compound that readily penetrates the epidermis and subsequent exposure to UV radiation (wavelengths greater than 320 nm). PPD is common among food handlers (eg, salad makers and grocery workers) and the most common compounds are limes and lemons used in mixing drinks or making lemonade. A history of helping parents to make such drinks or spilling juice on the body during outdoor activities may be present. In temperate countries, cases are often seen among children playing outdoors during summer, when psoralens are most abundant in wild and garden plants.
Berloque dermatitis refers to dermatitis that results from application of a psoralen-containing perfume (eg, oil of bergamot), followed by UV exposure. The patient develops a rash at the exact areas where the perfume was applied.
Figure 2.18 ▪ Phytophotodermatitis.
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