Burn Marks of Child Abuse

Information has been excerpted from VisualDx clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.


Physical abuse is the most frequently reported form of child abuse, with skin being the most commonly injured organ system. Abuse by burning comprises approximately 6–20% of all child abuse cases. Most abusive burn injuries occur on victims aged between 1 and 3 years. Stressors such as inconsolable crying, toilet training, and physical disabilities have been shown to increase likelihood of abuse in caregivers who are already stressed by limited emotional and physical resources. Assessment of the origin of burn injuries in this young age group can be particularly challenging because many of the children victimized are not yet verbal. The mortality rate of burns caused by abuse is greater than that of noninflicted burns. In general, when compared with accidentally burned children, abused children were significantly younger, had longer hospital stays, and had a higher rate of mortality. Burns resulting from neglect are another form of child abuse, even if they result from an act of omission.

Burns to the skin can be electrical, chemical, thermal, or radiant in nature. Various factors can influence the severity of a burn injury including the thickness of the skin, the length of contact with the source, the temperature of the agent, and the blood supply to the affected tissue. Electrical burns are quite subtle, and skin lesions may be inconspicuous or even absent. Such injury can cause prolonged tetany of muscles and should be considered when unexplained death or loss of consciousness occurs. Chemical burns are either acidic or alkaline and cause a prolonged period of burning due to residual product on the skin. Alkaline burns result in liquefaction and deeper injury.

The most common mechanisms used to inflict injury include immersion in scalding water, branding, and cigarettes. Microwaves and stun guns are rarer causes for inflicted injury. Sadly, any hot medium can be used as an instrument of abuse including common appliances such as hair dryers and irons. As with bruises, the pattern of injury suggests which instrument was used to inflict harm. In branding/contact burns, the imprint of a hot object is distinguished by uniform depth and clear margins. In contrast, only part of an object may be seen in nonintentional burns, since instinctual reflex allows the child to pull away from the pain.

It is important to note that cultural practices such as cupping, coining, and moxibustion lead to burn-like lesions in distinctive patterns. Proper evaluation is necessary, as the use of cultural practices does not exclude the potential for child abuse. In these cases, significant attention should also be focused on educating the parents to explain the adverse outcomes, discourage future harmful behavior, and suggest alternative forms of treatment.

Childhood physical abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds. It is estimated that each year over 3 million children are victims of abuse, with close to 2,000 fatalities secondary to maltreatment. Differentiating inflicted burns from those sustained accidentally or secondary to benign skin conditions can be challenging. However, a careful evaluation including the distribution, pattern, and history of the skin lesion in the context of the developmental capabilities of the child can help assess whether the injury was intentional.

Look For

Overall, mild burns appear as erythematous patches with or without edema. Moderate burns appear as vesicles or bullae that eventually turn to erosions. Ulcers can result from full-thickness burns. The pattern and distribution of the burn can be revealing.

Scalding is the most frequent form of burn abuse, with more than 80% resulting from tap water. Features of immersion burns of abuse include the following:

  • Uniform depth, with a sharp line of demarcation between burned and normal skin. In contrast, children who spill hot liquids usually burn the anterior portions of their body, and the severity of the burn dissipates as the liquid runs down the skin and cools.
  • 2nd to 3rd degree burns of hands and feet in a stocking-glove distribution.
  • There is an absence of splash marks in a forced submersion, whereas they are present in accidental injury, as the child withdraws from the painful stimulus.
  • Sparing of the thicker skin of palms or soles and of flexed skin folds is another common finding when a child is forcibly submersed in a flexed position, resulting in a “zebra stripe” scald pattern.
  • Burns in protected areas, such as the buttocks, perineum, head, or back. Diapers provide good protection against full-thickness scald injury, and it is unlikely that severe buttock burns would be endured by nonintentional immersion in hot water.
  • Dunking scald injuries occasionally have a “doughnut” pattern around the buttock area, which has been pressed against the cooler tub surface.
  • Symmetrically distributed burns.
  • Wounds necessitating skin grafting or intensive care.

In addition, burns in multiple sites or those in patterns consistent with the following mechanisms of injury are indicative of abuse:

  • Brands/contact burns (eg, from a hot plate)
  • Cigarette and cigarette lighters
  • Scalding immersion
  • Microwave oven (on pathologic tissue, subcutaneous fat is characteristically undamaged and may lie between significantly burned layers of skin and muscle)
  • Stun guns (multiple, paired lesions approximately 0.5 cm in diameter and 5 cm apart)
  • Fork tines
  • Light bulb
  • Iron or grill markings

Cigarette burns appear as punched-out ulcerations of about 8–10 mm with purple crusts, a nonexpanding dry base, and multiple layer involvement of the skin leading to rolled-appearing edges. Cigarette burns tend to be full thickness, third degree, and painless, with slow healing culminating in scar formation. Such inflicted lesions can become secondarily infected, increasing the difficulty in distinguishing the infection from the primary lesion.

Cultural Practices:
In cupping, a heated cup is inverted on the skin, typically on a child’s back, creating a suction force from the cooling and contracting air thought to “draw out” the ailment. Look for circular burns from the heat and central ecchymosis and petechiae from the suction effect.

In coining or spooning, oiled skin is rubbed firmly with the edge of a coin, producing linear erythematous marks, petechiae or purpura, usually on the back. There have been a few reported cases of serious complications from “coining” requiring skin grafts when the oil on the skin caught fire.

Moxibustion is used in Asian cultures for a variety of symptoms including fever and abdominal pain. It involves rolling pieces of moxa herb (mugwort or Artemisia vulgaris) or yarn into a small cone, igniting it on the skin over acupuncture points, and allowing it to burn until the onset of pain. The lesions of moxibustion appear as a pattern of 5–10 mm discrete, circular, target-like burns that may be confused with cigarette burns from child abuse.

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