6 A practical guide to the Istanbul Protocol – for medical doctors 1. Skin diseases 2. Non-torture-related lesions 3. Torture-related lesions. 1. DESCRIPTION OF SKIN LESIONS Torture sequelae related to the skin may be: Description of skin lesions should include the following points: 1. Lesions resulting from direct physical injuries 2. The occurrence of new – or aggravation of existent – skin diseases, provoked by physical or psychological trauma. When a doctor writes a certificate after conducting a medical examination of a person who alleges having been tortured, it is extremely important that the doctor states the degree of consistency with the history of torture (Allden et al., 2001). A conclusion indicating the degree of support to the alleged history of torture should be based on a discussion of possible differential diagnoses (non-torture-related injuries – including self-inflicted injuries – and skin diseases). The degree of support should be indicated as follows: 1. A high degree of support 2. Consistent with the alleged torture, moderate degree of support 3. Consistent with the alleged torture, slight degree of support 4. The changes cannot support the history of torture. Acute lesions are often characteristic since they show a pattern of inflicted injury that differs from non-inflicted injuries, e.g. by their shape and distribution on the body. Since most lesions heal within a short period of time, leaving no or non-specific scars, a characteristic history of the acute lesions is important. Also a history of the development until healing is of importance. 1. Localisation (use body diagram): symmetrical, asymmetrical 2. Shape: round, oval, linear, etc. 3. Size: (use ruler) 4. Colour 5. Surface: scaly, crusty, ulcerative, bullous, necrotic 6. Periphery: regular or irregular, zone in the periphery 7. Demarcation: sharply, poorly 8. Level in relation to surrounding skin: atrophic, hypertrophic, plane. The following findings are supportive of external infliction: 1. Lack of symmetry (may also be the case for some skin diseases) 2. Linear lesions in irregular or criss-cross arrangements 3. A linear zone extending circularly around an extremity 4. A regular, narrow, hyperpigmented or hypertrophic zone surrounding a scar (sequels to an inflammatory zone around a necrotic area), (may also be the case with skin diseases with necrotic areas, e.g. necrotic vasculitis). 2. BLUNT TRAUMA Blunt trauma may leave ecchymoses, contusions or lacerations with extravasation of blood in the skin and subcutaneous tissue, in some cases reflecting the shape of the instrument used, e.g. from beating with a stick (Rasmussen, 1990).