Abuse is the worst possible attack on a child's dignity and wellbeing, and the law protects children against any type of physical or psychological assault. In 1959, just over a century after Charles Dickens had denounced the vulnerability of children in Oliver Twist, the United Nations General Assembly adopted the Declaration of the Rights of a Child, considered to be the first legal manifesto for the protection of minors. In 1962, an article published by Kempe et al.1 on battered child syndrome profoundly changed how the victims of child abuse were cared for and raised public awareness, prompting the adoption of legal measures that directly affected children. In Spain, in addition to the legislation in different autonomous communities, the Organic Law 1/1996 for the Legal Protection of Minors, dated January 15, requires physicians to protect the physical and psychological integrity of children and to report any suspected assault, past or present.

Although it is beyond question that child abuse occurs, exact figures for its incidence in Spain are lacking. We do know that the number of reports is increasing, but it is difficult to count exactly how many cases there are because the physician involved may not know the procedure for filing the report, be worried about being wrong, or lack conclusive evidence of the cause of the lesions. In addition, some cases that are detected may go unreported because of the great shame associated with the problem. Finally, the paperwork for reporting child abuse varies in each autonomous community and differences in classification, collection, and processing of data make it hard to produce reliable national statistics.2

Skin lesions are present in 90% of child abuse cases, but dermatologists are rarely consulted to assess these lesions, probably because pediatricians expert in child abuse can recognize them readily. However, assessment of such lesions on a child when there is a suspicion of abuse may not be easy for a number of reasons. First, it can be difficult to recognize the signs of abuse. These can be very subtle when the abuse is continuous and longstanding. Moreover, the morphology and site of many different skin complaints can resemble abuse in an unabused child. The differential diagnosis includes a long list of conditions3–5 encompassing normal variants and relatively common diseases, such as genital forms of lichen sclerosus et atrophicus, molluscum contagiosum in the genitocrural folds, acute hemorrhagic edema of infancy, bullous impetigo, and ulcus vulvae acutum or Lipschütz ulcer. To untrained eyes, these may resemble sexual abuse, malicious blows, or deliberate burns. Second, sensitivity is required when questioning the child's parents or caretakers. The physician may be uncomfortable asking difficult questions that may irritate or frighten those responsible for the child. The situation is further complicated because the appearance of the parents or caretakers of the child often does not provide any clues that might arouse suspicion of child abuse. Third, it may be that the actual abusers are not the parents but someone else in the family or social circle. Thus, a suggestion of possible abuse may cause alarm, arouse suspicions, and have serious repercussions on family relationships. Fourth and last, when no other signs are present, clinicians often tend to unconsciously dismiss the suspicion of abuse because it is hard, if not impossible, to understand why anybody could behave so cruelly toward a child.

While the lesions reviewed in this issue of the journal may unequivocally point to abuse, we should also be aware of the lesions inflicted as a result of cultural customs, religious rites, or nutritional obsessions. Although these lesions are not intentional, the parents are not absolved of guilt and we cannot quietly ignore their presence. For example, ritual incisions, the application of very hot substances as a cure, or diets followed by strict vegetarians or vegans may lead to the appearance of permanent scars from wounds or burns, and deficiencies that endanger the child's wellbeing.6 Since as dermatologists we are obliged to safeguard the health of the child, the question that arises is whether it is our duty to report our suspicions to the appropriate authorities or whether an explanation of the origin of the lesions to the parents and subsequent follow-up on our part is an acceptable course of action.

Undoubtedly, any assessment of a child suspected of being abused should be multidisciplinary. The collaboration of pediatricians, specialists, social workers, and psychologists with experience in abuse will help us confirm our suspicions and allow the appropriate professionals to follow-up with the patients and their families. When there are solid grounds for suspicion, the competent legal body should be informed, usually the examining magistrate and public prosecutor responsible for minors. The process can be initiated even in the absence of complete certainty because the life of a child may be in danger. In any case, it is not the task of a physician to accuse anyone of abuse, but rather to ask the competent authorities to investigate the case. The case should also be reported anonymously to the corresponding register of the autonomous community to provide data for statistical analyses that will help instate programs aimed at detecting and preventing child abuse as well as providing information and support for the victims and the public in general.

Early detection is important to protect the child from further physical or psychological harm. Studies have shown the relationship between physical abuse and psychological disorders, with high rates of depression, anxiety, and a predisposition to drug abuse in abused patients.7 However, while it is our obligation to report any solid suspicion of abuse, to do so without good evidence could be very harmful for the child and the whole family. A failure to do our duty could cost the life of the child while an overzealous approach could destroy the reputation of an innocent person.