key: cord-0897395-pvkzk5v5 authors: Bascuas‐Arribas, Marta; Andina‐Martinez, David; Añon‐Hidalgo, Juan; Alonso‐Cadenas, Jose Antonio; Hernandez‐Martin, Angela; Lamagrande‐Casanova, Nuria; Noguero‐Morel, Lucero; Mateos‐Mayo, Ana; Colmenero‐Blanco, Isabel; Torrelo, Antonio title: Evolution of incidence of chilblain‐like lesions in children during the first year of COVID‐19 pandemic date: 2022-02-07 journal: Pediatr Dermatol DOI: 10.1111/pde.14948 sha: dac8d3ff8a0e572c9ec5d40ad9a311af03e7ff90 doc_id: 897395 cord_uid: pvkzk5v5 BACKGROUND: The COVID‐19 pandemic has brought innumerable reports of chilblains. The relation between pernio‐like acral eruptions and COVID‐19 has not been fully elucidated because most reported cases have occurred in patients with negative microbiological tests for SARS‐CoV‐2. METHODS: A retrospective study of 49 cases of chilblains seen during the first year of the pandemic in a children's hospital in Madrid, Spain. The incidence of these skin lesions was correlated with the number of COVID‐19 admissions and environmental temperatures. Patients were separated into two groups depending on the day of onset (strict lockdown period vs. outside the lockdown period). RESULTS: Most chilblains cases presented during the first and third waves of the pandemic, paralleling the number of COVID‐19 admissions. The first wave coincided with a strict lockdown, and the third wave coincided with the lowest ambient seasonal temperatures of the year. Systemic symptoms preceding chilblains were more frequent in the first wave (45.8% vs. 8.0%, p = .002), as was the co‐occurrence with erythema multiforme‐like lesions (16.7% vs. 0%, p = .033). Laboratory test and skin biopsies were performed more frequently in the first wave (75.0% vs. 12.0%, p < .001; and 25.0% vs. 0%, p = .007; respectively). Five patients developed recurrent cutaneous symptoms. CONCLUSIONS: An increased incidence of chilblains coincided not only with the two major waves of the pandemic, but also with the strict lockdown period in the first wave and low seasonal temperatures during the third wave. Both increased sedentary behaviors and cold environmental temperatures may have played an additive role in the development of COVID‐19‐related chilblains. consultant dermatologist who confirmed the diagnosis. After referral to the Dermatology Department, all cases were followed up either by onsite visit or by phone call. We recorded age, sex, personal history of previous diseases, contacts with potentially infected cases, skin symptoms, type and location of lesions, systemic symptoms, and outcomes. Laboratory analyses performed were also recorded, as well microbiologic tests We compared the occurrence of chilblains in children and adolescents during the year with the course of the pandemic and the mean environmental temperature in Madrid. The course of the pandemic in the Madrid region was measured by weekly hospital admissions rather than weekly new COVID-19 cases due to the fact that during the first months of the pandemic the availability of PCR was restricted to severe cases, thus making it impossible to address the real incidence of new cases. Data were obtained from the daily reports by the Health Authorities of Madrid region. 8 Due to natural evolution of SARS-CoV-2 infection, median time from the first symptom of COVID-19 to hospital admission is 7 days. 9 The median weekly temperature in Madrid was obtained from the registries of the State Meteorological Agency of Spain. 10 We searched for comparison the ED database for documented cases of chilblains or pernio during the previous 3 years. Data were analyzed using Stata version 15.0 (StataCorp). Variables with normal distribution were reported as mean and standard deviation. Variables that did not meet the normality requirements were reported as median and interquartile range. Variables within categories were expressed as percentages. Two-tailed t-tests were used to compare means between groups. Chi-squared tests were used to compare proportions. A p value <.05 was considered statistically significant. Approval from the institutional Ethics Committee and Board was obtained. Standard informed consents were obtained for recording images and for skin biopsies. Fifty-three patients were seen in the ED with acrally located erythemato-purpuric lesions consistent with chilblains. Two patients were excluded due to intense cold exposure at home without Age median (interquartile range) 13 (11) (12) (13) (14) 13 (11) (12) (13) (14) (15) 13 (11) (12) (13) (14) .473 Age group, n (%) Skin biopsies were obtained only during the first wave of the pandemic in 6 patients. No differences in duration of chilblains lesions between both groups were found. Up to 86% of patients (42/49) reported cutaneous symptoms lasted more than 4 weeks. The incidence of chilblains through the pandemic related to the incidence of weekly COVID admissions and median temperature in the Madrid region is reflected in Figure 1 . From March 2017 to February 2020, no documented patient with chilblains or pernio had presented to the ED of our institution. We identified three cases of recurrent cutaneous symptoms after being completely asymptomatic for more than 1 month in the first wave and two additional cases during the second period. They As reflected in Figure 1 , found that the incidence of chilblains increased during the pandemic. 12 Nevertheless, this study found a weak temporal correlation of COVID-19 cases with chilblain cases, concluding that the increase in the incidence may have resulted from behavioral changes. In our institution, we have found a dramatic increase in the incidence of pediatric chilblains during the COVID-19 pandemic with no cases diagnosed in the ED during the previous 3 years. Chilblain 15 Hubiche et al. observed a relatively high frequency of relapses in their chilblain-like cohort; one-third of the patients who had relapses were exposed to possible or proved cases of COVID-19 within the household, suggesting that re-exposure to SARS-CoV-2 infection might trigger a relapse in chilblain-like lesions. 16 Chilblains in children in the setting of COVID-19 pandemic Pernio-like skin lesions associated with COVID-19: a case series of 318 patients from 8 countries Most chilblains observed during the COVID-19 outbreak occur in patients who are negative for COVID-19 on polymerase chain reaction and serology testing No evidence of SARS-CoV-2 infection by polymerase chain reaction or serology in children with pseudo-chilblain SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases A clinical, histopathological and laboratory study of 19 consecutive Italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with COVID-19 infection Evaluation of chilblains as a manifestation of the COVID-19 pandemic Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Chilblain-like lesions and COVID-19: second wave, second outbreak Epidemiologic analysis of chilblains cohorts before and during the COVID-19 pandemic Approach to chilblains during the COVID-19 pandemic Acral changes in pediatric patients during COVID 19 pandemic: registry report from the COVID 19 response task force of the society of pediatric dermatology (SPD) and pediatric dermatology research alliance Relapse of chilblain-like lesions during the second wave of coronavirus disease 19 Relapse of chilblain-like lesions during the second wave of the COVID-19 pandemic: a cohort follow-up New insights in COVID-19-associated chilblains: a comparative study with chilblain lupus erythematosus Bilateral chilblain-like lesions of the toes characterized by microvascular remodeling in adolescents during the COVID-19 pandemic SARS-CoV-2, and COVID toes unified through cutaneous and systemic mechanisms From your nose to your toes: a review of severe acute respiratory syndrome coronavirus 2 pandemic-associated pernio How to cite this article: Bascuas-Arribas M Evolution of incidence of chilblain-like lesions in children during the first year of COVID-19 pandemic