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Unusual Lesions—Abuse or Accidental Injury?

Unusual Lesions—Abuse or Accidental Injury?

THE CASE
Because of the presence of unusual skin findings, a 3-year-old African American girl was evaluated for possible child abuse. The father, the primary guardian, reported that his daughter had returned home from her mother's residence 2 days before—a day earlier than planned. According to the father, the child was crying and had skin lesions, which initially appeared white and then darkened over the course of the next day or two. The mother did not know why the lesions appeared and stated that she had applied a salve to the involved areas.

When the girl was asked, 'How did you get these 'owies'?' she responded, "I swallowed it.' The findings on examination (in the photos shown) appeared virtually unchanged compared with those in photos taken by a detective 2 days earlier. The lesions were nontender and nonpruritic; they did not blanch with pressure. There was some slight discoloration around her mouth but no mucosal involvement.

The social history was significant for 21-year-old parents who did not live together. The father had primary custody because the mother "kept failing drug tests.' The mother practiced hairdressing in her home, and the father was a student. The girl's medical history was significant for mild anemia treated with oral iron. Development was normal and vaccines were up-to-date.

Are these lesions a result of an accident—or do they suggest abuse?
(Answer on next page)

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