TORONTO — Be suspicious if a child with a severe dermatologic condition is unresponsive to treatment, especially if their parent or caregiver exhibits deceptive behavior.
These could be red flags for Munchausen syndrome by proxy (MSBP), also known as factitious disorder.
"The number-one thing dermatologists can do in situations like this is be open to thinking outside the box and ask themselves the difficult question: Could this be something the parent is inflicting on the child," Kelly Frasier, DO, a dermatology clinical trials and epidemiology research fellow, at Northwell Health, Long Island, New York, told Medscape Medical News.
She provided a review on advancing the understanding of the dermatologic manifestations of MSBP during a poster session at the Society for Pediatric Dermatology (SPD) 2024 Annual Meeting. Frasier has a particular interest in psychodermatology — she was a mental health therapist before going to medical school.
MSBP is a type of abuse intentionally inflicted by a caregiver typically on their child "for some ulterior motive," usually to seek attention or sympathy and not for material or financial gain, explained Frasier. People with MSBP seek medical help for exaggerated or fabricated symptoms in their child. They may alter medical tests, falsify medical records, or induce symptoms in their child.
To do this, these abusers may apply any number of caustic household products, including glue, directly to the child's skin or even in formula. Frasier shared a picture of a baby whose formula had been doctored with a caustic substance that had dripped onto his neck and face, causing a rash with blisters.
In addition to blistering, cutaneous manifestations of MSBP can include severe bruising. Or the child may present with signs similar to those of granuloma annulare (a benign condition characterized by small, raised bumps) or cicatricial pemphigoid (a rare, chronic autoimmune blistering disorder) or may have recurrent nail avulsion, purpura, or coagulopathy, said Frasier.
In almost all cases of MSBP (an estimated 96%), the abuse is inflicted by the mother, who may have a preexisting mental illness. "Usually, a psychological disorder is at play, such as depression or anxiety," said Frasier.
Some evidence suggests that in cases of MSBP, the caregiver may have a personality disorder such as borderline or histrionic personality disorder — or may have suffered abuse or neglect as a child or is experiencing major stress, which some evidence suggests can trigger MSPB, she added.
This type of abuse is rarely seen in children older than 6 years, likely because they get wise to what's going on and are better able to fight back or resist as they get older, Fraser noted.
High Mortality Rate
It's critical that cases of MSBP are identified early. While a small proportion of child abuse cases involve MSBP, the mortality rate is extremely high, about 10%, research suggests, said Frasier.
Dermatologists should be skeptical if the child's condition hasn't improved despite trying numerous treatments that normally would have some effect. "If you're doing everything you can to treat something that's usually pretty simple in terms of what you normally see clinically and how you treat it, and you're not seeing any improvement or things continue to get worse, that's definitely a sign something else may be going on," Frasier said.
Another suspicious sign is inflammation that continues "for weeks or months" and "doesn't match up with actual lab markers and lab values," said Frasier.
Other signs of possible MSBP include evidence of chemicals in the child's blood, stool, or urine, or the child's condition improves while in the hospital, but symptoms return after returning home.
Also be aware of the interaction between the parent and child, said Frasier. "See if you can pick up that something else might be going on, especially if the symptoms aren't lining up very well with what you're physically seeing and what your clinical impression is."
And be suspicious of a parent's inappropriate behavior; for example, they seem to be deliberately making symptoms worse or appear overly distraught. The seemingly caring parent could be overcompensating for what she's doing at home, "and she wants to make sure it doesn't appear that way," said Frasier.
To help determine if some sort of trauma is occurring at home, the child would ideally be separated from the caregiver, perhaps with a nurse or other member of the interdisciplinary medical team, Frasier said.
It appears that pediatric dermatologists are already aware of the importance of protecting children from abuse. During a presentation at the meeting on child abuse and maltreatment in dermatology, not specifically on MSBP, Romy Cho, MD, assistant professor, Department of Pediatrics, University of Toronto, who is involved with the SCAN Program at The Hospital for Sick Children, Toronto, Ontario, Canada, polled the audience on whether they had ever contacted child protective services (CPS). Almost 80% said they had.
That's good news for Frasier. "We have to be willing to contact CPS if we think there's something going on, and be more open to that because it's better to be safe than sorry, especially in cases involving children."
Frasier and Cho had no relevant disclosures.