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.
Disclaimer:
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
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 commer-
cial 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 mech-
anisms, 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 examina-
tion related to skin findings, and understand the scope of forensics in
dermatology, including the types of wounds and patterns of injury to the
skin.
Date of release: May 2011
Expiration date: May 2012
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.

801

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802 Reddy and Lowenstein J AM ACAD DERMATOL
MAY 2011

The word ‘‘forensic’’ is derived from the Latin
forensis, meaning ‘‘a forum,’’ or ‘‘pertaining to the
law.’’1 Forensic pathology is defined as ‘‘the study
and application of medical and pathology principles
in determining the cause and manner of death in
cases of violent, suspicious, unexplained, unex-
of dermatologic findings in forensic pathology and
clinical forensics and highlight their significance.
POSTMORTEM SKIN CHANGES
Key points
d Normal gross postmortem skin changes in-

pected, sudden and medically unattended deaths.’’ clude algor mortis, livor mortis, and rigor
This definition has come to mortis
include clinical forensics, d Decomposition of the
which is concerned with the CAPSULE SUMMARY body occurs through au-
study of living victims.2 tolysis and putrefaction,
Examination of the skin is a critical part
d

With the formation of the or less commonly by

American Academy of
Forensic Sciences (AAFS) in
1948, sections including pa-
thology and biology, criminal-
istics, toxicology, engineering
sciences, questioned docu-
ments, forensic odontology,
anthropology, jurisprudence,
psychiatry, and general foren-
sic science were formally rec-
ognized.3 Many other areas in
forensics have been estab-
lished and play a crucial role,
such as forensic entomology.
Little has been published on
the subject of forensics in the
field of dermatology. Exami-
nation of the skin is a vital part
of the forensic examination,
often revealing patterns of in-
of the forensic examination, revealing
mummification, adiopo-
clues to the identity of an individual,
cere formation, freezing
time of death or injury, signs of internal
or freeze drying, or
disease, or external trauma.
tanning
Normal postinjury and postmortem
d d Focal dermoepidermal
changes in the skin and signs of disease separation, eccrine duct
or traumatic findings are described. necrosis, and dermal de-
Distinguishing wounds include injury generation are normal
from sharp (incised and stab wounds) or postmortem histologic
blunt (abrasions, contusions, and changes
lacerations) instruments, gunshot, burns,
electrocution, environmental It is important to recognize
(hypothermia, hyperthermia, drowning, the normal changes that oc-
and lightning) and vehicular injury. cur in the postmortem period
The patterns of injury can be telling with
d as distinct from traumatic in-
regard to the cause and circumstances of juries. One of the earliest
injury (ie, abuse, neglect, assault, self- changes seen after death is
inflicted injury, suicide, torture, algor mortis, or cooling of the
poisoning, and bioterrorism/biowarfare). body. The rate of cooling can
be affected by numerous fac-
Hair and nail findings can be informative
d

jury suggesting a particular tors, including body mass,

in forensic investigations.
etiology, signs of internal dis- body surface area, posture,
ease, or clues to the identity A dermatologist’s input is invaluable in
d
clothing, and environmental
and habits of the deceased. distinguishing pseudopathology from factors. Livor mortis, or post-
The dermatologist may rarely true pathology and aiding in the mortem hypostasis, is stain-
be called upon to render an diagnosis and management of forensic ing of dependent skin by
opinion regarding a suspi- cases. pooled intravascular blood.
cious death, but are likely to It begins to be evident about
encounter abuse or neglect in living victims. Recently, half an hour after death and by 6 hours has increased
dermatologists have played an important role in the significantly (Fig 1). It may appear even sooner in the
preparation for and identification of bioterrorism context of cardiac failure. Livor mortis spares me-
threats.4,5 In this two-part review, we offer an overview chanically compressed areas flattened by contact
with objects such as clothing, where pressure pre-
vents 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
a
Brooklyn, Brookdale University Hospital Medical Center, b was moved postmortem. Livor can shift if a body is
Brooklyn, and South Nassau Dermatology PC,c Oceanside and moved (blood remains fluid even after death because
Long Beach, New York. of the activity of fibrinolysin), but eventually be-
Funding 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,
1 Brookdale Plaza, Room 222A, Brooklyn, NY 11212. E-mail: clues. A victim of carbon monoxide poisoning may
evlow13@yahoo.com. have pink livor mortis, while methemoglobinemia
0190-9622/$36.00 can cause a brown lividity. Bronze hypostasis can be

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J AM ACAD DERMATOL
VOLUME 64, NUMBER 5
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 septice-
mia. Lividity can be distinguished from a contu-
sion by blanching the skin with the application of
pressure.6 A nonblanching contusion can be con-
firmed postmortem by the presence of extravas-
cular blood.2,6
Rigor mortis is the postmortem stiffening of mus-
cles. 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 temper-
atures, 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 un-
known, 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 en-
zymes causes enzymatic digestion of tissues, known
as autolysis. This is most prominent in organs with
high concentrations of enzymes, such as the pan-
creas. 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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Reddy and Lowenstein 803
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 un-
dergoes 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 de-
composition 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 subjec-
tive 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
804 Reddy and Lowenstein
Fig 2. Postmortem changes of decomposition with mar-
bling, 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 Time of death can be most accurately esti-
mated within the first 48 hours postmortem
based on algor mortis
d 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 sur-
face 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 exam-
ination of gastric contents, and on potassium levels
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J AM ACAD DERMATOL
MAY 2011
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 ante-
mortem from postmortem wounds, and aiding in the
determination of antemortem wound age.13 The vital
reaction is characterized by three phases (inflamma-
tion, 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 fibro-
nectin 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, intracel-
lular 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 ani-
mals, 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 irregu-
lar, 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
J AM ACAD DERMATOL
VOLUME 64, NUMBER 5
Table I. Molecular markers used in estimation of
wound age
Posttraumatic
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
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 mag-
gots or larvae of blow flies and beetles feeding on a
corpse, can determine with great accuracy informa-
tion 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 The medicolegal autopsy investigates ques-
tions related to the time, manner, and cause
of death
d Evidence should be carefully preserved
d Dermatoglyphs and other potentially identi-
fying marks should be documented
There are several considerations in handling bod-
ies 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
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Reddy and Lowenstein 805
removed. Injection sites should be circled in ink.
Surgical stab wounds should be labeled.
The medicolegal autopsy aims to answer ques-
interval tions related to the time, manner, and cause of death.
\30 min These include the identification of the body, the time
\30 min of death, the presence and significance of injuries or
[1 h natural disease, the presence of poisons, and the
[1.5 h interpretation of the effects of medical or surgical
[3 h therapies or procedures.6 An autopsy begins with
[4 h identification of the body, followed by measurement
[1 day of height and weight. The general appearance, build,
[1 day nutritional status, and state of hygiene should be
[1 day
noted. Clothing is described and examined, with an
attempt made to reconcile the location of torn cloth
[7 days
and wounds on the body.3 A thorough external
10-20 min examination is necessary, with particular attention
2-3 days given to the identifying marks.2 The hair and nails are
3 days examined, and samples can be taken for toxicologic
3 days analysis.
5 days 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 por-
tion of the external examination, a search for mate-
rial 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 histo-
logic 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 excep-
tions. Adermatoglyphia is a feature of Naegeli-
Franceschetti-Jadassohn syndrome and dermatopathia
pigmentosa reticularis, both autosomal dominant ker-
atin 14 gene disorders that map to a shared 6-cM
806 Reddy and Lowenstein
interval of chromosome 17q11.2-q21, and may repre-
sent 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 der-
matoglyphic findings.29
Identification by fingerprints is not always possi-
ble or successful. Forensic examiners look for other
potentially identifying marks on individuals, includ-
ing moles, ear imprints, scars, tattoos, and occupa-
tional 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 pig-
ments, 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 occu-
pational 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 Wounds are classified into three categories:
blunt force wounds, sharp force wounds,
and nonkinetic injuries
d The use of correct terminology when de-
scribing 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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J AM ACAD DERMATOL
MAY 2011
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 acci-
dents. Stretching abrasions are linear yellow abra-
sions 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 extravasa-
tion 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 second-
ary 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
J AM ACAD DERMATOL Reddy and Lowenstein 807
VOLUME 64, NUMBER 5

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 foren-
sic 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 deter-
mine 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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