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Mental health cases in pediatric dermatology

Experts discuss the cutaneous manifestations of Munchausen by proxy, child abuse, and eating disorders


Mental health cases in pediatric dermatology

Experts discuss the cutaneous manifestations of Munchausen by proxy, child abuse, and eating disorders


By Barbara Boughton, contributing writer

While most dermatologists spend their time treating primary skin conditions, they also play an important role in identifying mental health disorders with cutaneous manifestations in children. Research reveals that many of these children or their parents may show up in a dermatologist’s office for treatment of the skin symptoms, while they are often unwilling to go to a mental health provider for the underlying mental health problems (J Am Acad Dermatol. 2017; 76 (3): 779-791).

“It’s important for dermatologists to have a heightened awareness of the mental health disorders that may show skin symptoms,” said Margaret Lee, MD, PhD, director of dermatology pediatrics and assistant professor of dermatology and pediatrics at the Boston University School of Medicine. “Early diagnosis is crucial in the treatment of bulimia, anorexia, and the cutaneous side effects of child abuse.”

While dermatologists are most often called on to consult on child abuse cases with skin injuries, there are mental health disorders that can present with cutaneous symptoms in a dermatology office. 

Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) occurs when the child’s caregiver, usually a parent, injures a child or fakes a child’s illness in order to receive the attention that comes with repeated medical care and hospital admission. MSBP is thought to be rare since there have been relatively few cases reported in the scientific literature, said Alan Boyd, MD, director of the dermatopathology division and professor in the department of dermatology and pathology at Vanderbilt University in Nashville, Tennessee.

“Yet, I suspect Munchausen syndrome by proxy goes on more frequently than the literature represents,” Dr. Boyd said. Often when parents are confronted with a diagnosis of MSBP, they angrily leave the hospital, only to move on to another hospital, where the child will present again with dramatic and hard-to-identify illnesses, he added. In a paper published in the Journal of the American Academy of Dermatology, Dr. Boyd and fellow authors noted that there are three subtypes of MSBP: caregivers who cause the injury or illness, lie about the child’s symptoms, or feign the illness by manipulating blood and urine samples (2014; 71 (2): 376-381).

The psychological effect of MSBP on the child can be devastating, and there may also be long-term physical sequelae. In 8% of these cases, the abused child’s injuries can result in long-term physical consequences such as cognitive deficit, joint damage, and surgical complications. It is estimated that 9% to 12% of these patients die from their injuries. “Children of parents with MSBP can have abysmal long-term psychological issues, including behavior problems, eating disorders, problems with growth, suicidal ideation, depression, anxiety and PTSD,” Dr. Boyd said. In a few known cases, the patients developed Munchausen syndrome as adults, and go on to feign their own acute illnesses.

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The mean age for Munchausen syndrome is 35 years, but Dr. Boyd has treated a 17-year-old patient who began injecting paint thinner into his skin after his grandmother, an avid painter, died. “The boy had an abysmal home life but was close to his grandmother. The biopsies we did showed quite bizarre results. He did receive treatment and recovered, although he has long-term scarring,” Dr. Boyd added.

A parent of a patient with MSBP is often female, an excellent historian of the child’s illnesses, familiar with medical terminology, and has some background in the medical field. She may lavish inappropriate attention on the child with expensive clothing and many toys, and rarely leaves the child’s side at the hospital. Often the perpetrators have a history of being abused themselves, and their partners are often absent, distant, or disinterested.

Signs of MSBP include a medical history and skin symptoms that are not completely credible, and a long history of treatment at different medical clinics and hospitals. Often biopsy or lab results don’t align with physical findings, or cultures show organisms that are not commonly found in the skin. Test results may also be normal despite the mother’s stated history of her child’s illness, or the pediatric patient presents repeatedly with continued symptoms despite treatment, Dr. Boyd said.

When managing patients suspected of MSBP, it may be extremely helpful to contact other physicians who have treated the patient or obtain medical records, if possible, to verify details of the patient history. Cross-checking the child’s Social Security number and medical record numbers with other hospitals may reveal that the parent may have sought medical care under different aliases. Identifying and treating MSBP should begin with careful documentation, and the child should be admitted to a hospital or partial hospital program, where their actual signs and symptoms can be monitored without the parent present, according to a report published by the American Academy of Pediatrics (AAP) in 2007 (Pediatrics. 2007; 119 (5): 1026-1030).

Reporting the case to the appropriate authorities is crucial, as is working with a multidisciplinary child protection team to safeguard and treat the child effectively, according to the AAP paper. The entire family, if possible, should be involved in treatment since their view of illness and health must undergo adjustments. Ongoing family issues will also have to be addressed to aid the recovery of the parents and child (Pediatrics. 2007; 119 (5): 1026-1030). It should be noted that in most states, physicians, nurses, and other health care workers are required to report child abuse.

Child abuse

Skin symptoms can be the first clue that a pediatric patient is being abused. Up to 90% of pediatric abuse victims present with cutaneous findings, including bruises, burns, abrasions and lacerations, traumatic alopecia, and even bite marks (Contemporary Pediatrics. Oct. 1, 2015.) “It is important for dermatologists to know what the signs of child abuse are and how they are different from innocent injuries that might be mistaken for child abuse,” said Bernard Cohen, MD, professor of pediatrics and dermatology at Johns Hopkins Medical Center.

“Knowing the developmental parameters of children at different ages can help identify child abuse,” he added. “For the most part, a child who is six months old will not be walking so will not have access to things that might cause accidental burns or bruises,” he added.

A history of multiple injuries or injuries to multiple organ systems are potential signs of abuse, as are bruising or burns that are unlikely to have occurred accidentally. “Infants who are not walking should not have bruises on the shins like a child who is walking,” Dr. Lee said. “Any skin lesions or bruises that do not seem organic (i.e., have unusual geometric shapes or borders) should raise the index of suspicion for child abuse.” Injuries that are in the shape of belts, buckles, or stick, are also potential signs of child abuse (Clin Dermatol. 2017; 35: 504-511).

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In most cases of child abuse, the history is an important clue to the correct diagnosis. If the parent’s story changes or has inconsistencies, or it doesn’t match the child’s injuries, then dermatologists should suspect child abuse, Dr. Lee said. “I will often closely observe people’s faces when discussing the clinical history (with the parents or caretakers) to see if there may be a hidden subtext to their words,” she said.

Dr. Lee has evaluated children for suspicious burns with shapes like that of a clothing iron — often a sign of child abuse. Injuries that are bilateral, rather than one-sided, are also less likely to be accidental than those that are one-sided, she said.

Bruises are the most common injury in child abuse. Any bruise on an infant should prompt evaluation for possible abuse as well as for other underlying medical causes, since the likelihood of accidental bruising in a child who is not independently mobile is less than 1%. In any child, multiple bruises, large bruises, those in a defined pattern or away from bony prominences should increase suspicion for child abuse. Bruises or burns in an area of the body that is normally protected, such as the buttocks, back, trunk, inner thighs, earlobes, and neck can also indicate child abuse (Clin Dermatol. 2017; 35: 504-511).

Burns are evident in 6-20% of child abuse cases and are most common in children between age 12 months and three years. Their limited verbal skills can make evaluation difficult. Burns caused by child abuse are more likely to be fatal than accidental burns, so it is vital to recognize them. Most burns caused by abuse come from immersing the child in scalding water, contact with a burning hot substance or branding, and intentional burning with cigarettes. The burns are often on the buttocks or perineum and are in the shape of a hot object. Cigarette burns classically appear as punched-out ulcers 5-10 mm in size with purple crusts and well-defined edges.

Other kinds of child abuse include:

  • Sexual abuse, signaled by trauma in the genital or buttock area, infection with STDs, particularly multiple STDs.
  • Adult bites, which have a different pattern than the bites of an animal or small child (and are often not the result of abuse).
  • Child maltreatment that appears as prolonged and severe nutritional deficiencies when a child is not being fed enough food. Multiple bites, even child-sized ones, or a child that repeatedly presents with accidental injuries, can also be signs of neglect.
  • Traumatic alopecia with uneven or patchy hair loss, and broken hair strands. In child abuse cases, there can also be large amounts of hair loss in one area, sustained while the child’s hair is pulled or tugged. This needs to be differentiated from trichotillomania.

Potential cases of abuse with skin manifestations should be evaluated by a dermatologist comfortable with evaluating children with suspected child abuse and the hospital or clinic’s child protective services (CPS). These cases should also be reported to a local or state child protection agency even if the diagnosis is not definitive. “If you are unsure but can’t rule it out, it’s important to contact CPS,” Dr. Cohen said. “Not only are you obligated to report suspected child abuse, you are also protected if the injury turns out to have another cause,” he added.

What illnesses can look like child abuse but are actually "innocent" skin conditions?

According to experts and recent research, the following illnesses are sometimes mistaken for child abuse but can be accurately identified by dermatologists and other specialists (Contemporary Pediatrics. Oct. 1, 2015; Pediatr Dermatol. 2014; 31 (2): 146-155).

> Bruising and bone fractures: Caused by osteogenesis imperfecta or Ehlers-Danlos/hypermobility syndrome.

> Port wine stains: Can be identified by exam and medical history, since these are often present from birth.

> Mongolian spots or congenital dermal melanosis: Dermatologists can diagnose this benign congenital condition, which usually appears as bluish-gray patches on the lower back and buttocks, through history and physical exam. The patches usually disappear by age 10.

> Coagulopathies such as hemophilia, von Willebrand’s disease, and idiopathic thrombocytopenia purpura: Identified through CBC with platelets or a coagulation panel.

> Accidental ingestion of ex-lax® (sennosides) by toddlers, leading to severe burns on the buttocks: A rare reaction to the laxative, which can be identified through a careful history and by consultation with other specialists.

> Skin infections such as impetigo and cellulitis: Often diagnosed by exam and history. Since these are common conditions, cultures or skin biopsy are rarely needed.

> Staphylococcal scalded skin syndrome: A potentially serious skin infection, diagnosed by a complete medical history, physical exam, and sometimes skin biopsy. “It produces superficial ulcerations that can mimic scald injuries. If you touch the skin when it first pops up, the skin will just slough off,” Dr. Cohen said. The peeling skin can affect large parts of the body.

> Genital warts in children under age three: “In young children, genital warts can be transmitted non-sexually — during delivery if the mother has HPV or if a caregiver with HPV changes the child’s diapers. In such cases, it’s best to get a careful history of the parents, child, and any other caregivers, and to test for other STDS to identify child sexual abuse,” Dr. Cohen said. “In children over age three with genital warts, the index of suspicion for sexual abuse has to be much higher,” he added.

Eating disorders and the skin

Scientific reports have identified at least 40 dermatologic signs of eating disorders, particularly in anorexia and bulimia. “These disorders present often with skin manifestations alone, caused by starvation and/or malnutrition, self-induced vomiting, drug consumption (usually laxatives, diuretics, and appetite suppressants) or concomitant psychiatric disorders. Unfortunately, skin signs usually appear when the eating disorder is severe (i.e., body mass index ≤16 kg/m2 in anorexia nervosa),” said George Kroumpouzos, MD, PhD, clinical associate professor of dermatology at the Alpert Medical School at Brown University.

Patients with eating disorders are also at high risk for self harm, including cutting and burning. “You may see multiple parallel pink or brown lines or scars, most often on the inner forearm,” Dr. Lee said.

In a review study published by Dr. Kroumpouzos and colleagues in 2017, the researchers noted that skin manifestations are more common in anorexia than bulimia. Amenorrhea is a key diagnostic feature of anorexia, while the characteristic skin sign of bulimia is the Russell’s sign (knuckle calluses). Bulimia has also been linked to polycystic ovary syndrome (J Am Acad Dermatol. 2017; 76 (3): 779-791).

Women comprise more than 90% of all patients with an eating disorder, and first-time cases usually occur by age 25, Dr. Kroumpouzos said. The lifetime prevalence of anorexia among women is 4% and for bulimia, the prevalence in females is 2%, he added. Men make up only 5% to 10% of patients with bulimia or anorexia (JEADV. 2002; 16 Suppl. 1: 303).

Common skin signs of anorexia include asteatotic skin, xerosis, follicular hyperkeratosis, carotenoderma, hyperpigmentation, acne, pruritis, and facial dermatitis, Dr. Kroumpouzos said. Hair and nail changes also occur, including alopecia, opaque hair, and nail fragility, according to Renata Strumia, MD, an expert in eating disorders and the skin, who practices in Ferrara, Italy. Anorexic patients will also have oral cavity symptoms such as angular cheilitis, gingivitis, and taste abnormalities, she added (Strumia R, ed. Eating disorders and the skin. Springer-Verlag Berlin Heidelberg; 2013).

Self-induced vomiting and purging are features of both anorexia and bulimia. The use of laxatives, diuretics, and appetite suppressants can result in urticarial eruptions, fixed drug eruptions, finger clubbing from laxatives containing senna, and photosensitivity (J Am Acad Dermatol. 2017; 76 (3): 779-791). The most apparent signs of self-induced vomiting are the Russell’s sign and enamel tooth erosion. “The knuckle lesions involve calluses on the dorsal aspects of the dominant hand induced by the patient’s repeated introduction of the hand into the mouth,” Dr. Strumia said. “It is a guiding sign in the diagnosis of an eating disorder,” she added.

The guiding signs of eating disorders are strong clues of an occult and undiagnosed eating disorder, Dr. Strumia said. “Identifying the guiding signs is important, because the prognosis of patients with eating disorders is linked to early diagnosis,” she added. In addition to knuckle calluses, the guiding signs of an eating disorder include lanugo-like body hair due to starvation, tooth enamel erosions, and self-induced dermatoses. Dr. Kroumpouzos noted that the presence of at least one guiding sign plus four of the characteristic signs of eating disorders are required to make a diagnosis.

Although males make up a minority of eating disorder cases, the lifetime prevalence in men has risen by a reported 28.9% since the publication of the most recent DSM-5 diagnostic criteria, Dr. Strumia said. In men, the guiding cutaneous signs of an eating disorder may be absent, since they are more likely to practice excessive fasting and exercise, rather than self-induced vomiting and laxative abuse. “The drive for thinness is less evident in males, since muscular shape may hide a significant loss of fat mass,” she said. “As a result, diagnosis in men is often delayed and severe medical complications can develop,” Dr. Strumia added. The most prevalent skin manifestations of an eating disorder in men are due to severe medical complications, such as hematological alterations (JEADV. 2002; 16 Suppl. 1: 303.)

A dermatologist who identifies skin signs of an eating disorder should refer the patient to a clinic specializing in eating disorders. “Eating disorders are psychiatric conditions complicated by multiple organ dysfunctions, and require a multidisciplinary team approach, including management by a specialist in eating disorders,” Dr. Kroumpouzos said.

Cognitive behavioral therapy has been shown to be successful in bulimia, although it has yielded poor results in anorexic patients, he said. Fluoxetine is FDA-approved for bulimia and olanzapine, a second-generation antipsychotic agent, may help promote weight gain and improve psychological symptoms in patients with anorexia. The skin manifestations of eating disorders may require dermatologic therapies, but usually disappear with treatment of the underlying condition, Dr. Kroumpouzos noted.

“It can be difficult for a patient with an eating disorder or their parents to accept a referral to a psychiatrist, even if they recognize that the child has a problem with food,” Dr. Strumia said. “If I explain that I will be referring them to a center with a multidisciplinary medical team, that suggestion is often well-accepted.”