Dermatologic disorders can mimic child abuse.
Phytophotodermatitis, also known as "inadvertent PUVA" or "lime disease," is a harmless photoeruption induced by sun exposure following skin contact with psoralens in limes and certain other plants. There are several reports in the literature of the disorder's mimicking of child abuse, either by appearing as bruises from imprinted finger marks (Am. J. Dis. Child 1985;139:239-40) or as a burn injury (J. R. Soc. Med. 1997;90:560-1).
The usual presentation of phytophotodermatitis is pigmentation that arises in bizarre patches and fades very slowly. Occasionally, the condition can cause bullae or vesicles. Nearly all cases in the United States are caused by limes, although ornamental oranges, clover, and celery can also trigger the eruption following sun exposure. Blacks may have less reaction, but all races are susceptible, said Dr. Hansen, professor of dermatology and pediatrics at the University of Arizona, Tucson.
The phenomenon commonly occurs when a child has lime juice on his or her skin--either from touching the fruit directly or from contact with someone else who has--and then is exposed to sunlight. The degree of reaction depends on the amount of the psoralen absorbed into the skin and the amount of sun exposure.
Because there is often a delay between the sun exposure and the changes in skin pigmentation, it's important to elicit an exposure history going back several days. Dr. Hansen said.
Patients should be advised that the problem can be prevented in the future by hand washing and/or sun avoidance after contact with plants containing psoralen, he said.
Lichen sclerosus, previously known as lichen sclerosus et atrophicus, also may arouse concern about child abuse. A vulvar dystrophy seen in both post menopausal women and children younger than 7 years, the disorder may be hard to recognize on the skin, appearing as a marginated, whitish, purpuric patch. Examination of the vulva and perianal area, however, reveals the distinct characteristic figure-eight hypopigmentation, with purpura and telangiectasia. Genital pain, itching, and burning on urination are common symptoms of lichen sclerosus in young girls.
"This is what I see more and more of. I'm now following about 20 little girls with this, and it's a real problem," Dr. Hansen noted.
Anal symptoms--including fissures, pain on defecation, bleeding, avoidance of defecation, stool hoarding, and encopresis--are also common in these patients and often missed.
In a British series of 15 girls aged 18 months to 9 years with lichen sclerosus, half had prominent anal symptoms. However, Dr. Hansen said, "I think it's higher than 50%. In my experience, 85%-90% of little girls with lichen sclerosus have very prominent anal symptoms. It's something we have to work with."
To distinguish lichen sclerosus from sexual abuse, "you need to have a good light and know what it looks like. You can make a clinical diagnosis most of the time, but not all of the time. Sometimes you need a biopsy." Dr. Hansen noted that he sends female patients to the operating room for a genital biopsy, rather than perform the procedure in his office.
Treatment is lubrication and the same ultrapotent topical steroids used in mature women. Such use is not harmful, because the steroid is applied to the vulva and not the groin. "It's remarkable. Within 2 weeks, I can't see any abnormality. It obliterates the disease," Dr. Hansen said.
Lichen sclerosus in young girls usually remits prior to puberty, although occasionally it persists into adolescence, he said.
BY MIRIAM E. TUCKER
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|Title Annotation:||Clinical Rounds; Phytophotodermatitis, lichen sclerosus|
|Author:||Tucker, Miriam E.|
|Date:||Apr 1, 2007|
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