Forensics in dermatology: Part I

CONTINUING

MEDICAL EDUCATION

Forensics in dermatology: Part I Kalpana Reddy, MD,a and Eve J. Lowenstein, MD, PhDa,b,c Brooklyn, Oceanside, and Long Beach, New York

CME INSTRUCTIONS The following is a journal-based CME activity presented by the American Academy of Dermatology and is made up of four phases: 1. Reading of the CME Information (delineated below) 2. Reading of the Source Article 3. Achievement of a 70% or higher on the online Case-based Post Test 4. Completion of the Journal CME Evaluation CME INFORMATION AND DISCLOSURES Statement of Need: The American Academy of Dermatology bases its CME activities on the Academy’s core curriculum, identified professional practice gaps, the educational needs which underlie these gaps, and emerging clinical research findings. Learners should reflect upon clinical and scientific information presented in the article and determine the need for further study. Target Audience: Dermatologists and others involved in the delivery of dermatologic care. Accreditation The American Academy of Dermatology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation The American Academy of Dermatology designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditsÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. AAD Recognized Credit This journal-based CME activity is recognized by the American Academy of Dermatology for 1 AAD Recognized Category 1 CME Credits and may be used toward the American Academy of Dermatology’s Continuing Medical Education Award.

activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to the diagnostic, management and treatment options of a specific patient’s medical condition.

Disclosures Editors The editors involved with this CME activity and all content validation/ peer reviewers of this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Authors The authors of this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Planners The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Resolution of Conflicts of Interest In accordance with the ACCME Standards for Commercial Support of CME, the American Academy of Dermatology has implemented mechanisms, prior to the planning and implementation of this Journal-based CME activity, to identify and mitigate conflicts of interest for all individuals in a position to control the content of this Journal-based CME activity. Learning Objectives After completing this learning activity, participants should be able to define forensic terminology, describe aspects of the forensic examination related to skin findings, and understand the scope of forensics in dermatology, including the types of wounds and patterns of injury to the skin.

Disclaimer:

Date of release: May 2011 Expiration date: May 2012

The American Academy of Dermatology is not responsible for statements made by the author(s). Statements or opinions expressed in this activity reflect the views of the author(s) and do not reflect the official policy of the American Academy of Dermatology. The information provided in this CME

Ó 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2010.05.050

Examination of the skin and adnexae is a critical part of the forensic examination. Little information on forensic sciences has been published in the dermatologic literature. Correct forensic terminology and documentation of dermatologic findings is of critical importance in forensic investigations. The skin may reveal clues to the identity of an individual and the time and method of death or injury. Normal postmortem changes in the skin are described along with pseudopathology and damage from postmortem animal activity. The forensic classification of types of injuries is introduced in this first of a two-part paper on forensics in dermatology. ( J Am Acad Dermatol 2011;64:801-8.) Editor’s note: We recognize that readers may find portions of these articles disturbing. As you read, please consider the importance of recognizing cutaneous signs of abuse and neglect, as well as the possible consequences of ignorance of these signs. Key words: abuse; bioterrorism; forensic medicine; gunshot wounds; homicide; neglect; poisoning; pseudopathology of skin; self-inflicted injury; suicide; torture.

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The word ‘‘forensic’’ is derived from the Latin of dermatologic findings in forensic pathology and forensis, meaning ‘‘a forum,’’ or ‘‘pertaining to the clinical forensics and highlight their significance. law.’’1 Forensic pathology is defined as ‘‘the study and application of medical and pathology principles POSTMORTEM SKIN CHANGES in determining the cause and manner of death in Key points d Normal gross postmortem skin changes incases of violent, suspicious, unexplained, unexpected, sudden and medically unattended deaths.’’ clude algor mortis, livor mortis, and rigor This definition has come to mortis d Decomposition include clinical forensics, of the CAPSULE SUMMARY which is concerned with the body occurs through austudy of living victims.2 tolysis and putrefaction, Examination of the skin is a critical part or less commonly by With the formation of the of the forensic examination, revealing mummification, adiopoAmerican Academy of clues to the identity of an individual, cere formation, freezing Forensic Sciences (AAFS) in time of death or injury, signs of internal or freeze drying, or 1948, sections including padisease, or external trauma. tanning thology and biology, criminalNormal postinjury and postmortem d Focal dermoepidermal istics, toxicology, engineering changes in the skin and signs of disease separation, eccrine duct sciences, questioned docuor traumatic findings are described. necrosis, and dermal dements, forensic odontology, Distinguishing wounds include injury generation are normal anthropology, jurisprudence, from sharp (incised and stab wounds) or postmortem histologic psychiatry, and general forenblunt (abrasions, contusions, and changes sic science were formally reclacerations) instruments, gunshot, burns, ognized.3 Many other areas in electrocution, environmental It is important to recognize forensics have been estab(hypothermia, hyperthermia, drowning, the normal changes that oclished and play a crucial role, and lightning) and vehicular injury. cur in the postmortem period such as forensic entomology. as distinct from traumatic inLittle has been published on The patterns of injury can be telling with juries. One of the earliest the subject of forensics in the regard to the cause and circumstances of changes seen after death is field of dermatology. Examiinjury (ie, abuse, neglect, assault, selfalgor mortis, or cooling of the nation of the skin is a vital part inflicted injury, suicide, torture, body. The rate of cooling can of the forensic examination, poisoning, and bioterrorism/biowarfare). be affected by numerous facoften revealing patterns of inHair and nail findings can be informative tors, including body mass, jury suggesting a particular in forensic investigations. body surface area, posture, etiology, signs of internal disA dermatologist’s input is invaluable in clothing, and environmental ease, or clues to the identity distinguishing pseudopathology from factors. Livor mortis, or postand habits of the deceased. true pathology and aiding in the mortem hypostasis, is stainThe dermatologist may rarely diagnosis and management of forensic ing of dependent skin by be called upon to render an cases. pooled intravascular blood. opinion regarding a suspiIt begins to be evident about cious death, but are likely to half an hour after death and by 6 hours has increased encounter abuse or neglect in living victims. Recently, significantly (Fig 1). It may appear even sooner in the dermatologists have played an important role in the context of cardiac failure. Livor mortis spares mepreparation for and identification of bioterrorism chanically compressed areas flattened by contact threats.4,5 In this two-part review, we offer an overview with objects such as clothing, where pressure prevents blood from filling subcutaneous veins. Livor mortis is particularly useful in establishing if the body From The State University of New York Health Science Center at was moved postmortem. Livor can shift if a body is a b Brooklyn, Brookdale University Hospital Medical Center, moved (blood remains fluid even after death because Brooklyn, and South Nassau Dermatology PC,c Oceanside and Long Beach, New York. of the activity of fibrinolysin), but eventually beFunding sources: None. comes fixed with hemolysis and decomposition. In Reprint requests: Eve J. Lowenstein, MD, PhD, Chief of addition to the location of livor, the hue can provide Dermatology, Brookdale University Hospital Medical Center, clues. A victim of carbon monoxide poisoning may 1 Brookdale Plaza, Room 222A, Brooklyn, NY 11212. E-mail: have pink livor mortis, while methemoglobinemia [email protected]. 0190-9622/$36.00 can cause a brown lividity. Bronze hypostasis can be d

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Fig 1. Livor mortis/ hypostasis on the back of a man, with sparing of mechanically compressed areas. (Courtesy of the Office of the Chief Medical Examiner, The City of New York.)

seen in cases of Clostridium perfringens septicemia. Lividity can be distinguished from a contusion by blanching the skin with the application of pressure.6 A nonblanching contusion can be confirmed postmortem by the presence of extravascular blood.2,6 Rigor mortis is the postmortem stiffening of muscles. Anoxia and inadequate amounts of adenosine triphosphate, with subsequent build-up of lactate and phosphate in muscle tissue, results in an acidic environment that promotes the binding of actin and myosin fibers. Rigor occurs uniformly throughout the body but is first visible in the face and neck at 1 to 4 hours postmortem and the remainder of the body by 12 hours postmortem. Certain circumstances may lengthen the duration of rigor, such as cold temperatures, or accelerate the rate of rigor development, such as death from status epilepticus from strychnine poison.7 Rigor mortis begins to fade at 24 hours, and can also be used to help determine if a body was moved after death.6 In rare cases, instantaneous rigor mortis, also known as cadaveric spasm/cataleptic rigidity, may be observed. While its cause is unknown, it has been associated with intense emotions and violent deaths (ie, drownings), with the corpse found in a position that crystallizes its last activity. Cutis anserina (goose bumps) is one of the earliest manifestations of rigor mortis, caused by rigor of the pili erector muscles.8 Two processes contribute to decomposition of the body. The postmortem release of cellular enzymes causes enzymatic digestion of tissues, known as autolysis. This is most prominent in organs with high concentrations of enzymes, such as the pancreas. Decomposition is also mediated via the activity of bacteria in a process called putrefaction. Decomposition becomes evident in the intestines at 24 to 36 hours postmortem and is accelerated by ambient heat and sepsis. A green discoloration

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appears on abdominal skin, beginning over the right cecum. The green coloration is a product of hemoglobin decomposition by gut flora that have moved into the skin. The trunk and extremities exhibit purple to brown venous distention, known as marbling, which is caused by bacterial spread through the venous system. Gas production at 60 to 72 hours causes generalized swelling or bloating, which can result in bulging of the eyes and tongue, swelling of the face, abdomen, and breasts, and prolapse of genitals. At 3 to 5 days postmortem, blister formation and skin and hair slippage may be seen (Fig 2). Handling the body easily results in denuded areas. Skin slippage may be difficult to distinguish from postmortem scalds, which have a similar appearance. At 3 to 4 weeks postmortem, skin appendages such as hair and nails detach easily from the body. Although putrefaction is the most common form of decomposition, some environments favor other processes. In arid climates, the body slowly undergoes mummification, or dessication. A thin body habitus is more likely to dessicate. Another process, adipocere formation, or saponification, occurs in alkaline, humid, and cool conditions because of hydrolysis and hydrogenation of subcutaneous fat.9 Adiopocere is usually noted on the face, breasts, and buttocks, and can appear as quickly as 3 weeks postmortem, but it often takes months to develop. Adiopocere appears as a pale, greasy semifluid substance in the early phases, and progresses to a waxy, firm, grey compound. Another type of decomposition is known as washerwoman’s hand or foot, which is caused by maceration in bodies removed from water (Fig 3). Different types of decomposition can occur in the same body.2,6,10 Freezing, freeze drying, and tanning (from bog exposure) are other mechanisms of postmortem preservation that may be encountered. Histologic examination of the skin has also been shown to provide clues to the time of death. In a small study performed in a temperate climate, focal dermoepidermal separation, eccrine duct necrosis, and dermal degeneration were noted within 1 week of death. Dermal degeneration, characterized by subtle changes including subjective rarefaction of the dermis, prominence of elastic fibers with mild splitting, and deterioration into small eosinophilic fragments was consistently observed in nondependent truncal skin biopsy specimens taken on day 2 postmortem. Eccrine duct necrosis, with vacuolization and ballooning of epithelial cells, indistinct cytoplasmic borders, and focal decrease in nuclear detail, was observed at days 4 to 7 in truncal skin.11

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Fig 2. Postmortem changes of decomposition with marbling, bloating, and skin slippage. (Courtesy of the Office of the Chief Medical Examiner, The City of New York.)

Fig 3. Washerwoman’s hand on a body found in water. (Courtesy of the Office of the Chief Medical Examiner, The City of New York.)

ESTIMATION OF TIME OF DEATH AND WOUNDS Key points d

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Time of death can be most accurately estimated within the first 48 hours postmortem based on algor mortis Gross and histologic examination of wounds can aid in distinguishing antemortem from postmortem wounds and provide evidence of antemortem wound age

Estimations of time of death are most accurate within 48 hours of death and vary with temperature, body location, diurnal variation, sex, exercise, congestive heart failure, fat content, age, body surface area, and other variables. The most accurate methods of estimating time of death in the early postmortem period are based on algor mortis, which is one of the earliest signs of death.12 Forensic entomology is useful in estimating the time of death, with insects and larvae found in various stages of growth being informative. Older methods, such as those based on livor and rigor mortis, on the examination of gastric contents, and on potassium levels

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in the vitreous fluid have been used, but they are unreliable indicators of the time of death.6 Gross and histologic examination of wounds is critical in providing evidence to distinguish antemortem from postmortem wounds, and aiding in the determination of antemortem wound age.13 The vital reaction is characterized by three phases (inflammation, proliferation, and maturation) analogous to the phases of wound healing. When present, the vital reaction is indicative of antemortem injury.14,15 The advancement of immunohistochemistry and cellular biology has added to our understanding of the vital reaction. The cell adhesion protein fibronectin is the most sensitive marker of wound age, appearing within a few minutes of injury.14 Other molecular markers of wound age are summarized in Table I.14 Bruises can be a sign of abuse or a consequence of disease and a useful timing indicator. Despite classic teachings suggesting that a clear progression of color changes exists in bruises, gross bruise colors have not been shown to be a reliable predictor of bruise age in two large studies.16,17 Spectrophotometry has also been studied as a method to determine the age of bruises by measuring products of hemoglobin degradation, such as hemosiderin and bilirubin.18 Spectrophotometry can also help localize the depth of a bruise, with deeper bruises appearing more blue (Tyndall effect) and superficial bruises appearing redder. Additional studies need to be completed to evaluate this technique.18,19 Histologically, intracellular hemosiderin in macrophages results from the digestion of extravasated red blood cells and can be used to estimate wound age. Contusions feature erythrocytes in macrophages at 15 to 17 hours postmortem.20 Significant hemosiderin deposits ([20% of the microscopic field, arbitrarily defined at any magnification) suggest a bruise age of more than 1 week.15,20

POSTMORTEM DAMAGE CAUSED BY ANIMAL ACTIVITY Key points d

Postmortem damage can be caused by animals, rodents, or insects and may provide clues about the victim’s time, season, and location of death

Animals can cause postmortem damage. Mice and rats produce round or crater-like lesions with irregular, finely scalloped or serrated margins. The presence of parallel cutaneous lacerations is pathognomonic for rodent incisor bites. Associated findings, such as rodent feces or hair near the body, further support rodent activity as the etiology.21 Postmortem damage

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Table I. Molecular markers used in estimation of wound age Marker

Tumor necrosis factorealfa P-selectin E-selectin Intercellular adhesion molecule-1 Vascular cell adhesion molecule-1 Interleukin-1-alfa Interleukin-8 Monocyte chemotactic protein-1 Macrophage inflammatory protein-1-alfa Vascular endothelial growth factor Extracellular matrices Fibronectin Collagen III Collagen V Collagen VI Collagen I

Posttraumatic interval

\30 min \30 min [1 h [1.5 h [3 h [4 h [1 day [1 day [1 day [7 days 10-20 min 2-3 days 3 days 3 days 5 days

Adapted from Kondo14 and Oehmichen.15

by carnivores, such as cats or dogs, has also been reported. Puncture sites caused by canine teeth resemble stab wounds, and damaged areas have more rounded irregular margins than rodent wounds. Claw marks in the form of linear abrasions may be seen near the wound.22 Bodies may also be damaged by the infiltration of insects. Different insects are attracted to the body at different times after death.8 Forensic entomologists, via their analysis of the maggots or larvae of blow flies and beetles feeding on a corpse, can determine with great accuracy information about the victim’s time, season, and location of death and determine the postmortem movement or storage of the body and the submersion interval.23

THE STANDARD FORENSIC EXAMINATION Key points d

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The medicolegal autopsy investigates questions related to the time, manner, and cause of death Evidence should be carefully preserved Dermatoglyphs and other potentially identifying marks should be documented

There are several considerations in handling bodies in a medicolegal case. Bodies should not have the hands pried open, but rather paper bags should be placed over them to preserve any evidence. All wounds and bite marks should be photographed. Bullets should be recovered. No tubing should be

removed. Injection sites should be circled in ink. Surgical stab wounds should be labeled. The medicolegal autopsy aims to answer questions related to the time, manner, and cause of death. These include the identification of the body, the time of death, the presence and significance of injuries or natural disease, the presence of poisons, and the interpretation of the effects of medical or surgical therapies or procedures.6 An autopsy begins with identification of the body, followed by measurement of height and weight. The general appearance, build, nutritional status, and state of hygiene should be noted. Clothing is described and examined, with an attempt made to reconcile the location of torn cloth and wounds on the body.3 A thorough external examination is necessary, with particular attention given to the identifying marks.2 The hair and nails are examined, and samples can be taken for toxicologic analysis. A careful search for wounds is undertaken, which are classified by the mechanism of mechanical injury (ie, blunt trauma, sharp weapon injury, or gunshot wounds).13 The location of each wound is described in relation to anatomic landmarks. In the final portion of the external examination, a search for material or DNA evidence is performed. Before any internal examination, imaging may be performed in order to document the presence and location of metallic foreign bodies (in cases of knife or gunshot wounds) or to show evidence of previous fractures (in cases of suspected abuse). The internal organs are then subjected to both gross and histologic examination.3 The most commonly used, highly reliable form of identification in forensics is fingerprinting. Acral sweat ducts open along the fingerprint ridges. The presence of lipids in sweat gland secretions results in a greasy secretion in which a fingerprint is imprinted whenever the individual touches a smooth surface.24 The unique pattern of arches, loops, and whorls, along with the positions of tiny defects on fingerprint ridges, are used to characterize the print. The chance of two individuals having the same fingerprints, or dermatoglyphs, is estimated to be 1 in 64 billion.6 It is therefore important for the pathologist to retain the epidermis from the fingers, even if it detaches postmortem. If the epidermis has been lost, lower quality prints can be made from the dermis. Palms or soles are an alternative source of prints that are unique to an individual.2 Dermatoglyphics are ubiquitous with rare exceptions. Adermatoglyphia is a feature of NaegeliFranceschetti-Jadassohn syndrome and dermatopathia pigmentosa reticularis, both autosomal dominant keratin 14 gene disorders that map to a shared 6-cM

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interval of chromosome 17q11.2-q21, and may represent variants of the same disorder.25-28 Abnormal glyphs may be a feature of several other disorders, including Down (trisomy 21), Patau (trisomy 13), Turner, and Klinefelter syndromes. Schizophrenia, leukemia, congenital heart disease, alopecia areata, and psoriasis have been associated with specific dermatoglyphic findings.29 Identification by fingerprints is not always possible or successful. Forensic examiners look for other potentially identifying marks on individuals, including moles, ear imprints, scars, tattoos, and occupational marks. Distinguishing marks are carefully measured and described in the forensic report. When examining tattoos, it should be remembered that pigments, especially red, green, or blue pigments, fade over time. In these cases, pigment may be found in the draining lymphatic glands. Black and blue tattoos produced with carbon pigment are often resistant to fading and remain present for long periods of time. New types of tattoos have evolved to include black light tattoos, eyeball tattooing, and skin carving.30 The examiner also searches for occupational marks that support a purported history of a particular type of work, such as calluses specific to the instrument played by musicians, or traumatic tattooing of coal on miner’s hands.24

TYPES OF WOUNDS Key points d

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Wounds are classified into three categories: blunt force wounds, sharp force wounds, and nonkinetic injuries The use of correct terminology when describing wounds is critical

In forensics, wounds are classified into three categories according to the type of causative force. Abrasions, contusions, and lacerations are blunt force wounds, while incised, stab, and chop wounds are classified as sharp force wounds. The third category includes nonkinetic injuries (thermal, chemical, and electrical injury). The use of correct terminology when describing wounds is critical because the judicial system relies upon physician’s descriptions and documentation of a wound using proper forensic terminology. Abrasions are the most superficial type of blunt injury and are caused by tangential impacts or direct crush injury. By definition, the epidermis is the only skin layer involved. Bleeding may be noted in deep abrasions, from blood vessels in the dermal papillae. The analysis of torn epidermal fragments at the edge of the abrasion can show the direction of force applied to the skin. Classic types of abrasions include

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Fig 4. Stretching abrasions on the central chest after a motor vehicle accident. (Courtesy of the Office of the Chief Medical Examiner, The City of New York.)

friction burn, gravel rash, or stretching abrasions, all of which are frequently seen in motor vehicle accidents. Stretching abrasions are linear yellow abrasions secondary to rotational stretch of the skin beyond its elastic capacity (Fig 4). Abrasions caused by crush injuries include bite marks, in which the pattern of the contacting object can often be seen.6 The application of force to intact skin, with damage to blood vessels and subsequent extravasation of blood, results clinically in bruise formation or contusions (Fig 5). Generally, bruises progress through a series of color changes as a result of hemoglobin breakdown, helping to distinguish ‘‘new’’ bruises (red, purple, or blue) from ‘‘old’’ bruises (green, yellow, or brown).31 Factors that affect the extent of bruise formation include site of injury, type and force of mechanical trauma, and internal factors unique to the individual, such as a coagulopathy or medicinal anticoagulation therapy. Loose skin tissue, areas with greater amounts of subcutaneous fat, brittle vessels secondary to photodamage, the presence of blood thinners, and poor support of blood vessels (as in the elderly), all predispose to bruising.20 Ecchymoses can appear either immediately or some time after the injury. They may appear at the injury site or at a distant site. Tracking of blood along fascial planes can prevent the retention of the pattern of the contacting object.6 Oblique force applied to the skin, especially over bony structures such as the scalp or joints, causes the skin to stretch and tear, resulting in a laceration. Lacerations are characterized by irregular margins and bridging fibers (typically nerves, fibrous bands of fascia, or medium-sized blood vessels that have resisted the injuring force).6 Sharp force wounds include incised, stab, and chop wounds. These wounds are classified by their depth and length. The length of an incised wound is greater than its depth (Fig 6). Conversely, stab wounds have greater depth than length, making them more lethal. Chop wounds are both deep and long, a reflection of the weapon implemented in the

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Fig 5. A, Patterned contusion on the abdomen induced by a seatbelt during a motor vehicle accident. B, Contusion on labia of 5-year-old female. The suspicion of abuse was allayed when the mother reported that the child slipped while coming out of the bath, a story consistent with the injury.

classic aspects, including postmortem skin changes and classes of injury. In the following review, we focus more on ‘‘living forensics’’—patterns of injury observed and detected in the living victims of forensic injury.

Fig 6. Defensive incised wound on a victim’s hand between the thumb and index finger. (Courtesy of the Office of the Chief Medical Examiner, The City of New York.)

injury. The amount of bruising at the wound margins is used to determine the sharpness of the injuring object.6 Wound morphology can be used to determine the shape of the penetrating weapon. For instance, scissors classically cause a Z-shaped wound. Skin tension and Langer lines must be taken into account when determining a wound’s original morphology. Elastic fibers perpendicular to the wound cause it to become rounder, while parallel tension lines distort the appearance by lengthening the wound and making it appear more slit-like.32 The third type of wound results from the use of a nonphysical force, such as thermal, chemical, or electrical injury. A more detailed description of these types of wounds follows in the discussion of patterns of injury in the second part of this two-article series.

CONCLUSIONS The topic of forensic pathology as it relates to dermatology is vast. We have looked at the more

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14. Kondo T. Timing of skin wounds. Leg Med (Tokyo) 2007;9: 109-14. 15. Oehmichen M. Vitality and time course of wounds. Forensic Sci Int 2004;144:221-31. 16. Bariciak ED, Plint AC, Gaboury I, Bennett S. Dating of bruises in children: an assessment of physician accuracy. Pediatrics 2003; 112:804-7. 17. Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Child 2005;90:187-9. 18. Hughes VK, Ellis PS, Burt T, Langlois NE. The practical application of reflectance spectrophotometry for the demonstration of haemoglobin and its degradation in bruises. J Clin Pathol 2004;57:355-9. 19. Bohnert M, Baumgartner R, Pollak S. Spectrophotometric evaluation of the colour of intra- and subcutaneous bruises. Int J Legal Med 2000;113:343-8. 20. Vanezis P. Interpreting bruises at necropsy. J Clin Pathol 2001; 54:348-55. 21. Tsokos M, Matschke J, Gehl A, Koops E, Puschel K. Skin and soft tissue artifacts due to postmortem damage caused by rodents. Forensic Sci Int 1999;104:47-57. 22. Tsokos M, Schulz F. Indoor postmortem animal interference by carnivores and rodents: report of two cases and review of the literature. Int J Legal Med 1999;112:115-9. 23. Campobasso CP, Introna F. The forensic entomologist in the context of the forensic pathologist’s role. Forensic Sci Int 2001; 120:132-9. 24. Polson CJ, Gee D, Knight B. The essentials of forensic medicine. New York: Pergamon Press; 1985. pp. 72-83, 312.

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25. Heimer WL 2nd, Brauner G, James WD. Dermatopathia pigmentosa reticularis: a report of a family demonstrating autosomal dominant inheritance. J Am Acad Dermatol 1992; 26:298-301. 26. Lugassy J, Itin P, Ishida-Yamamoto A, Holland K, Huson S, Geiger D, et al. Naegeli-Franceschetti-Jadassohn syndrome and dermatopathia pigmentosa reticularis: two allelic ectodermal dysplasias caused by dominant mutations in KRT14. Am J Hum Genet 2006;79:724-30. 27. Sprecher E, Itin P, Whittock NV, McGrath JA, Meyer R, DiGiovanna JJ, et al. Refined mapping of Naegeli-FranceschettiJadassohn syndrome to a 6 cm interval on chromosome 17q11.2-q21 and investigation of candidate genes. J Invest Dermatol 2002;119:692-8. 28. Itin PH, Lautenschlager S, Meyer R, Mevorah B, Rufli T. Natural history of the Naegeli-Franceschetti-Jadassohn syndrome and further delineation of its clinical manifestations. J Am Acad Dermatol 1993;28:942-50. 29. Verbov J. Clinical significance and genetics of epidermal ridges—a review of dermatoglyphics. J Invest Dermatol 1970;54:261-71. 30. JewelEye-innovative body piercing update. Available at: http:// www.technovelgy.com/ct/Science-Fiction-News.asp?NewsNum =84. Accesed April 24, 2009. 31. Jenny C, Hay TC. The visual diagnosis of child physical abuse. Elk Grove Village, IL: American Academy of Pediatrics; 1994. 32. Byard RW, Gehl A, Tsokos M. Skin tension and cleavage lines (Langer’s lines) causing distortion of ante- and postmortem wound morphology. Int J Legal Med 2005;119:226-30.