Skin manifestations during the COVID‐19 pandemic in the pediatric emergency department

Abstract

Background The role of SARS‐CoV‐2 as the cause of chilblains in children remains a matter of debate but it is important to elucidate it for patient isolation and contact tracing. We sought to define the etiology, clinical presentation, time course, and outcomes of children presenting to the emergency department (ED) with cutaneous manifestations shortly after the first pandemic peak of COVID‐19 in Spain. Methods A prospective, observational study in children <15 years of age evaluated for skin lesions in the EDs of three pediatric hospitals. Children underwent a comprehensive work‐up including tests for SARS‐CoV‐2 antibodies and polymerase chain reaction (PCR), and serology and PCR tests for other viruses and bacteria. A 1 month follow‐up visit was conducted. Results From April 14 through May 8, 2020, we enrolled 62 children. Of those, 34 had acro‐ischemic skin lesions and 28 had a variety of skin rashes. Overall, 40% of children had mild systemic symptoms. Children with chilblains were older, had pain more frequently and a more prolonged duration of skin lesions, while those with non‐specific rashes had fever more frequently. Lesions were resolved in 75% of children at follow up. Five patients demonstrated SARS‐CoV‐2 antibodies, and none tested positive with PCR. Three additional patients tested positive with PCR for rhinovirus, Mycoplasma pneumoniae and Chlamydia pneumoniae. Conclusions The number of ED visits for chilblains, which are rare in pediatrics, was high soon after the first peak of COVID‐19 in Spain. The disease course was self‐limited, outcomes were favorable, and the possibility of viral transmission was negligible as all patients tested negative for SARS‐CoV‐2 by PCR.

Chilblains-Like Lesions in Pediatric Patients: A Review of Their Epidemiology, Etiology, Outcomes, and Treatment

“…Two hundred and forty-five lesions were edematous, and there were five cases of dactylitis ( 11 , 12 , 15 , 19 , 20 , 24 , 27 , 31 , 34 , 38 , 39 , 41 , 48 , 55 ). Other findings included 68 cases of erosions, 65 cases of vesicles, and 63 cases of blisters/bullae ( 6 , 11 , 13 , 15 – 17 , 20 , 26 , 27 , 31 , 35 , 37 – 39 , 42 , 43 , 47 , 48 , 51 , 54 ). There were 24 cases with lesion blanching, and 23 cases with ulcers ( 10 , 11 , 13 , 22 , 38 ).…”

“…In most cases, patients did not report systemic symptoms of illness prior to the onset of chilblains-like lesions ( 11 , 14 , 17 , 20 – 24 , 26 , 29 , 30 , 32 , 36 , 37 , 52 , 53 , 57 ). However, there have been reports of systemic symptoms occurring prior to, concurrent with, or following the appearance of chilblains-like lesions.…”

“…Two hundred and ten cases had possible contact with SARS-CoV-2, 116 cases had contact with a known SARS-CoV-2 case, and an additional 13 cases had possible or definite contact with a SARS-CoV-2 contact ( 10 – 25 , 28 , 30 , 31 , 33 , 36 , 37 , 42 , 47 – 49 , 51 , 52 , 54 ) Supplementary Table S3 .…”

“…The majority of cases did not have evidence for other infections, such as Mycoplasma pneumoniae , enterovirus, human metapneumovirus, coxsackie virus, herpes simplex virus, Epstein-Barr virus (EBV), Cytomegalovirus (CMV), parvovirus B19, Bartonella henselae , and Rickettsia conorii ( 16 , 19 , 23 , 27 , 28 , 34 – 37 , 47 , 49 – 51 ). Supplementary Table S4 .…”

“…A large study of 378 cases reported lesions resolving an average of 21.6 days after onset, though the median time to resolution was 14 days ( 11 ). Other reported outcomes included the following: a majority of 71 cases had a median resolution time of 47 days, 19 cases resolved between 14 and 30 days, 17 cases resolved after a mean of 27 days, eight cases had resolution by a median of 7 days, and seven cases resolved by 8 weeks ( 12 , 14 , 18 , 37 , 48 ). Unspecified times to resolution are also reported: Table 3 .…”