key: cord-0861586-r2ed0ego
authors: Garcia‐Lara, G; Linares‐González, Laura; Ródenas‐Herranz, Teresa; Ruiz‐Villaverde, Ricardo
title: Chilblain‐like lesions in pediatrics dermatological outpatients during the COVID‐19 outbreak
date: 2020-05-06
journal: Dermatol Ther
DOI: 10.1111/dth.13516
sha: 26746ef6fb4f122504527cbfb5f9d765fa1c2451
doc_id: 861586
cord_uid: r2ed0ego

nan

In Spain, with full confinement measures imposed by the national government and coinciding with the pandemic, Pediatricians and Dermatologists, have received, through teledermatology/teleconsultation and social networks, a barrage of diverse images, which have subsequently allowed us to approach some of them by direct physical examination of early and late skin manifestations associated with SARS-Cov-2 infection [1] [2] [3] [4] . In particular, acro-ischemic lesions, similar to chilblain ("chilblain-like") have been highlighted in children and adolescents with little or no symptoms, located at fingers and toes. COVID + epidemiological environment have not always been able to be proved 2,5 . Even with a clear and well established temporal relationship, there is no demonstrable evidence of infection in many cases people. However, the skin has allowed us a privileged observation of the evolution of a sign, based on a morphology that is repeated in each focus of the pandemic. The causal relationship and the possibility that can be considered a later sign of the infection remains to be elucidated.

We designed a retrospective, cross-sectional study to evaluate the dermatological care of all those patients under the age of 16 who consulted, in person or telematically, for acral lesiones (chilblain-like or erythema multiforme-like) in the context of the COVID-19 pandemic, since March 15 to 24 April 24 of 2020, both included in the health area of the Hospital Universitario San Cecilio de Granada. Inclusion criteria were the presence of acral skin lesions as the reason for consultation. Exclusion criteria included another type of cutaneous lesions and lack of clinical data. The variables collected included, sex, age, personal history of chilblain / Raynaud's disease, type of lesions, symptoms, location (hands/feet), tests for SARS-COV-2 (PCR, Ig M, Ig A, Ig G), Non-cutaneous clinic, Family affected by the SARS-COV-2 infection and treatment for skin lesions. All parents signed an informed consent before the inclusion of the patient in the present study.

All the results obtained are reflected on Table 1 . Of all the patients collected, 18 (66%) were male and the overall mean age was 14.44 years. All lacked a personal history of interest and denied previous episodes of chilblains or Raynaud's phenomenon/disease. The clinic was limited to purpuric lesions located on acral regions distributed on hands and feet ( Fig.1-3) , asymptomatic or associated with pruritus (11%) or mild pain (22%). Regarding systemic symptoms related to SARS-Cov-2 infection, no respiratory symptoms were observed and only one of them had suffered an episode of diarrheal outbreak coinciding with the skin symptoms. No need of administration of local or systemic treatment was necessary and the lesions resolved spontaneously without sequelae.

Many clinical signs of this virus have been described including new cutaneous manifestations. It is not uncommon for viral infections to cause skin rashes, for example, measles, rubella, and dengue fever allcause viral exanthems (6) . However, cutaneous manifestations are considered an infrequent presentation of COVID-19. Recalcati (1) reported the first large analysis on the skin manifestations of 148 COVID-19 positive patients in Lecco Hospital in Italy. The author described cutaneous symptoms in 20,4% of patients with 3 main patterns: erythematous rash, urticaria, and chickenpox-like lesions. Since then, subsequent case reports and case series have described COVID-19 associated skin lesions, to highlight the epidemic of cases of vasculopathy-related skin manifestations in healthy young patients. The lesions typically occur in children and adolescents and they mainly affect the feet and sometimes the hands. They appear as red-violet macules, which can cause blisters and usually evolve favourably. These acute selfhealing acroischemic lesions are different from other chronic conditions such as acrocyanosis, perniosis, or vasculitis. Although they could be the expression of secondary micro thrombosis due to endothelial damage (2) its clinical implication and relation to COVID-19 remains unclear. Early recognition, especially on the pediatric population, of cutaneous manifestations, is important for the monitoring and surveillance of younger patients.

Our series is focused on pediatric patients, whose parents have consulted in the southern area of Granada with a reference population of approximately 250,000 inhabitants. The results differ from some published series (7, 8) where multiforme-like erythema eruptions seem to occur in a younger population, although in our case most of the consulted cases were identified as chilblain-like. It is difficult to establish a relationship with SARS-Cov-2 infection and even the few tests performed offer negative serological results. Currently, the serological panel has been expanded to CMV, EBV, Parvovirus B19 and Mycoplasma pnuemoniae to try a better understanding regarding the appearance of these lesions in the current epidemiological context, as a high number of incident pediatric cases at this season is an uncommon fact. It would have been desirable to obtain samples for histological study in these patients.

Dermatologists and paediatricians should be aware of the lesions associated with COVID-19 infection and their possible complications. It remains to be identified if there are different dermatological patterns in the pediatric and adult population. However, this will require further studies to develop protocols applicable to clinical practice.

Cutaneous manifestations in COVID-19: a first perpective

A new vasculitis at the time of COVID-19

Lesiones pernióticas y acrales en España durante el confinamiento por COVID: Análisis retrospectivo de 12 casos

Manifestaciones cutáneas en el contexto del brote actual de enfermedad por coronavirus 2019

Coronavirus (COVID-19) infection induced chilblains: a case report with histopathological findings

Viral exanthem in COVID-19, a clinical enigma with biological significance

Chilblain-like lesions on feet and hands during the COVID-19 Pandemic