key: cord-0755740-amhc0ryh
authors: Ruggiero, Giuseppe; Arcangeli, Fabio; Lotti, Torello; Ametrano, Orsola; Ruggiero, Cosimo; Cucchiara, Salvatore; Oliva, Salvatore
title: Reply to: “Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak”
date: 2020-06-01
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.05.122
sha: b188599b1cbcab282a8454bfec98b9aade5f508b
doc_id: 755740
cord_uid: amhc0ryh

nan

We read with interest "Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak" [1] . Cutaneous manifestations of COVID-19 are rarely reported. Fernandez-Nieto et al. in their letter described an increased number of acro-ischemic lesions in young patients from Spain [1] .

Most patients were asymptomatic or mildly symptomatic, and none of them developed COVID-19 pneumonia or any other complication.

It is very intriguing that in Italy we are observing the same uncommon increase. Italy and Spain are the two European countries with the highest incidence of COVID-19 [2] . In Italy, after the outbreak onset, many general pediatricians reported on our pediatric dermatology network unusual foot injuries, similar to chilblains and without any other symptoms. These lesions have never been described with this frequency before, being usually rare. Thus, we Table 1 ). The Spanish authors found 132 cases in 41 days, while our patients were collected in 10 days. Even in our cohort, lesions were mostly located in the extremities of the limbs, with only two cases involving the face. We found a lower rate of systemic symptoms (16% vs 25%), but our population was slightly younger (mean age 12.5 vs 23.4 years), being likely less symptomatic [3] . Almost the same number of positive SARS-CoV-2 tests (1 vs 2 patients) was described in both cohorts. Our positive patient had also extra-cutaneous symptoms (fever and pharyngodynia). He was exposed to positive Covid-19 subjects (family members) as in the Spanish positive ones. This confirms that the chance of finding infected children increases if all cohabiting family members are tested after an index case. Indeed, only 11% in our cohort were tested for Sars-CoV-2, due to the rigid testing policy in Italy. The Spanish group tested only 8%, thus confirming the difficulty in having testing in overwhelmed public health systems.

We did not differentiate between chilblains-like and Erythema multiforme-like lesions. We observed and collected only lesions appearing as circumscribed erythematous edematous elements with a purplish red color, thus defined "Erythema Pernio-like lesions" (Figure 1) . A local and/or systemic therapy was considered only in 74/100 cases (74%) ( Table 1 ). Up to 80% of cases at day 12 had a favorable outcome regardless of the therapy used. This observation is additional evidence for a COVID-19 etiology. Indeed, it is known that chilblains can be secondary to viral infections. The likelihood of other seasonal non-COVID-19 infections was extremely low since children were having contact only with their family members due to the national lockdown [4] .

Pernio-like" acrolocated lesions onset and COVID-19. General pediatricians all over the world should pay attention to skin lesions during the COVID-19 pandemic. 

Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department

Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak

Epidemiological characteristics of 2143pediatric patients with 2019 coronavirus disease in China

Delayed access or provision of care in Italy resulting from fear of COVID-19

The authors would like to especially thank the following key persons for contributing in data