Case 2: Rash and allegations of neglect

A 16-month-old boy with an extensive rash was brought to the emergency department by his mother's boyfriend. This person had left the household 1.5 months earlier and had not seen the child since his departure; he was shocked on his return to discover an extensive rash on the young boy (Figure 1). An extensive rash on a 16-month-old boy presenting to the emergency department The boyfriend made a number of allegations of neglect against the boy's mother, including improper nutrition. There was no pain, pruritus or fever. The boy's medical history revealed occasional diaper rashes. Growth parameters were normal. The boy was pale but happy. Confluent erythematous scaly plaques covered the back, abdomen, axillae and periorbital areas. On the perineum, the rash was clearly demarcated at the diaper edges, beefy red, glistening, desquamating and not showing much scaling. The intertriginous zones were not spared. The legs and arms showed evidence of pink papules and xerosis. The scalp showed extensive golden dry scales with little erythema. Some excoriations exhibited a golden discharge. Both ear canals contained purulent material. Retroauricular and sub-mandibular lymphadenopathy was noted. The remainder of the physical examination was normal. Laboratory investigations revealed a normal albumin level, a hemoglobin concentration of 110 g/L, and normal platelets and white blood cells. A subspecialty consultation revealed the diagnosis. A dermatologist was consulted and psoriasis was diagnosed. A discussion with the boy's mother revealed that his biological father had a history of psoriasis. Psoriasis has its onset in childhood in approximately one-third of patients. A family history is often present because the disease is associated with a number of human leukocyte antigens. Clinically, the disease can present in a number of forms. As in adults, an extensor distribution of the lesions is the most common presentation in children, but the lesions tend not to be as extensive and have a finer scale. Children often have more frequent facial and intertriginous (retroauricular, axillary and anogenital) involvement. In infants, atypical presentations of psoriasis can make the condition difficult to diagnose. Although neglect and inadequate hygiene can produce significant perineal dermatitis, the resulting exanthem tends to be painful, often sparing intertriginous areas. Involvement of other areas of the body should lead one to consider a broader differential diagnosis. Some infants with perineal psoriasis may be erroneously diagnosed with persistent diaper dermatitis; however, psoriatic exanthems tend to be painless and involve the intertriginous areas. Occasionally, diaper psoriasis can disseminate and progress rapidly to involve the entire body, a condition termed diaper psoriasis with dissemination. Another condition, diaper dermatitis with psoriasiform id reaction, is a reaction to diaper candidiasis and has a similar appearance. The child in the present case exhibited a significantly widespread dermatitis amid allegations of neglect and malnutrition. The diagnosis became clear early in the investigative process, limiting the testing performed. Other cases may not be as straightforward and may initially be confused with child abuse or neglect. A number of generalized and localized conditions can be mistaken for child abuse. Malnutrition, though it can result from either neglect or medical disease, can cause striking dermatological findings as a result of vitamin and mineral deficiency. Acrodermatitis enteropathica and dermatitis herpetiformis are two other diffuse dermatological conditions that can be mistaken for neglect with failure to thrive. However, these conditions are related to zinc malabsorption and gluten enteropathy, and are relatively easy to diagnose with laboratory tests. Other conditions, such as the rashes of eczema and Henoch-Schönlein purpura, the appearance of scarring in Ehlers-Danlos syndrome and various drug eruptions, have also been known to fool physicians into suspecting child abuse. Concerning localized skin eruptions may result from phytodermatitis. This results from a phototoxic reaction to psoralens from certain juices and can leave imprints of hands or objects. Discolouration of the skin from clothing or dyes can be confused with bruising. On the perineum, lichen sclerosus et atrophicus can cause bruise-like changes in the skin of the vulva, and senna-containing laxatives can cause a dermatitis of the buttocks so severe as to mimic a burn. Severe dermatitis in infants can be due to neglect, but a careful look at the history, features and extent of the rash may yield an underlying diagnosis. Psoriasis can present in infants as persistent diaper dermatitis. Several rashes suspicious for child abuse have underlying medical causes. The case presentation should not exceed 200 words and should give the reader enough information to suspect the diagnosis without making it obvious. The discussion should not exceed 600 words and should be followed by a couple of ‘clinical pearls’. A maximum of two references may be included, if helpful. The submitted cases will undergo peer review and revision at the discretion of the editors. Priority is given to cases illustrating an approach to common problems or important clinical clues to less common diagnoses that should not be missed. The Editorial Board hopes that this provides an opportunity for trainees and paediatricians practising outside of the teaching hospitals to share their clinical experiences and to publish in Paediatrics & Child Health. If you have a case to submit, contact Dr Friedman by e-mail at jeremy.friedman@sickkids.ca.

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