Skin manifestations of COVID-19 in children: Part 3

D Andina 1, A Belloni-Fortina 2, C Bodemer 3, E Bonifazi 4, A Chiriac 5, I Colmenero 6, A Diociaiuti 7, M El-Hachem 7, L Fertitta 3, D van Gysel 8, A Hernández-Martín 1, T Hubiche 9, C Luca 5, L Martos-Cabrera 1, A Maruani 10, F Mazzotta 4, A D Akkaya 11, M Casals 12, J Ferrando 13, R Grimalt 14, I Grozdev 15, V Kinsler 16, M A Morren 17, M Munisami 18, A Nanda 19, M P Novoa 20, H Ott 21, S Pasmans 22, C Salavastru 23, V Zawar 24, A Torrelo 1; ESPD Group for the Skin Manifestations of COVID-19

Affiliations

01 April 2021

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doi: 10.1111/ced.14483

Abstract

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions, and in Part 2 we expanded to other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In this part of the review, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Figures

Figure 1 Algorithm for diagnosis of COVID‐19 in children with a skin eruption. IHC, immunohistochemistry; LDH, lactate dehydrogenase; PIMS, paediatric inflammatory multisystem syndrome. *Fever > 38 °C, muscle pain, headaches, asthenia, cough, dyspnoea, nausea/vomiting/diarrhoea and anosmia/agueusia.

Figure 1 Algorithm for diagnosis of COVID‐19 in children with a skin eruption. IHC, immunohistochemistry; LDH, lactate dehydrogenase; PIMS, paediatric inflammatory multisystem syndrome. *Fever > 38 °C, muscle pain, headaches, asthenia, cough, dyspnoea, nausea/vomiting/diarrhoea and anosmia/agueusia.

Figure 2 (a,b) Histopathology of chilblains in COVID‐19: (a) intense perivascular and perieccrine infiltrates; (b) oedema in the papillary dermis with both dermoepidermal and perivascular infiltrates; (c,d) prominent lymphocytic vasculitis with vessel wall damage in dermal vessels. Haematoxylin and eosin, original magnification (a) × 2; (b) × 10; (c) × 40; (d) × 100.

Figure 2 (a,b) Histopathology of chilblains in COVID‐19: (a) intense perivascular and perieccrine infiltrates; (b) oedema in the papillary dermis with both dermoepidermal and perivascular infiltrates; (c,d) prominent lymphocytic vasculitis with vessel wall damage in dermal vessels. Haematoxylin and eosin, original magnification (a) × 2; (b) × 10; (c) × 40; (d) × 100.

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KMEL References

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References

  1.  
    1. Hoang A, Chorath K, Moreira A et al. COVID‐19 in 7780 pediatric patients: a systematic review. EClinicalMedicine 2020; 24: 100433. - PMC - PubMed
  2.  
    1. Rodriguez‐Jimenez P, Chicharro P, De Argila D et al. Urticaria‐like lesions in COVID‐19 patients are not really urticaria – a case with clinicopathologic correlation. J Eur Acad Dermatol Venereol 2020. 10.1111/jdv.16618 - DOI - PMC - PubMed
  3.  
    1. Kaya G, Kaya A, Saurat JH. Clinical and histopathological features and potential pathological mechanisms of skin lesions in COVID‐19: review of the literature. Dermatopathology (Basel) 2020; 7: 3–16. - PMC - PubMed
  4.  
    1. Mahé A, Birckel A, Merklen C et al. Histology of skin lesions establishes that the vesicular rash associated with COVID‐19 is not ‘varicella‐like’. J Eur Acad Dermatol Venereol 2020; 34: e559–61. 10.1111/jdv.16706 - DOI - PMC - PubMed
  5.  
    1. Llamas‐Velasco M, Chicharro P, Rodríguez‐Jiménez P et al. Reply to "Clinical and histological characterization of vesicular COVID‐19 rashes: a prospective study in a tertiary care hospital": pseudoherpetic Grover disease seems to appear in patients with COVID‐19 infection. Clin Exp Dermatol 2020. 10.1111/ced.14305 - DOI - PMC - PubMed
  6.  
    1. Elsaie ML, Youssef EA, Nada HA. Herpes zoster might be an indicator for latent COVID 19 infection. Dermatol Ther 2020: e13666. 10.1111/dth.13666 - DOI - PMC - PubMed
  7.  
    1. Elsaie ML, Nada HA. Herpes zoster (shingles) complicating the course of COVID19 infection. J Dermatolog Treat 2020: 1–3. 10.1080/09546634.2020.1782823 - DOI - PubMed
  8.  
    1. Magro C, Mulvey AJ, Berlin D et al. AGRO, complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID‐19 infection: a report of five cases. Transl Res 2020; 220: 1–13. - PMC - PubMed
  9.  
    1. Bosch‐Amate X, Giavedoni P, Podlipnik S et al. Retiform purpura as a dermatological sign of covid‐19 coagulopathy. J Eur Acad Dermatol Venereol 2020; 34: e548–9. 10.1111/jdv.16689. - DOI - PMC - PubMed
  10.  
    1. Sanchez A, Sohier P, Benghanem S et al. Digitate papulosquamous eruption associated with severe acute respiratory syndrome coronavirus 2 infection. JAMA Dermatol 2020;156: 819. 10.1001/jamadermatol.2020.1704 - DOI - PubMed
  11.  
    1. Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [The epidemiological characteristics of an outbreak of novel coronavirus diseases (COVID‐19) in China] (in Chinese). Zhonghua Liu Xing Bing Xue Za Zhi 2019; 2020(41): 141–51. - PubMed
  12.  
    1. Centers for Disease Control and Prevention. Interim guidelines for collecting, handling, and testing clinical specimens from persons for coronavirus disease 2019 (COVID‐19). Available at: https://www.cdc.gov/coronavirus/2019‐nCoV/lab/guidelines‐clinical‐specim... (accessed 5 June 2020).
  13.  
    1. Ludvigsson JF. Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults. Acta Paediatr 2020; 9: 1088–95. - PMC - PubMed
  14.  
    1. Sethuraman N, Jeremiah SS, Ryo A. Interpreting diagnostic tests for SARS‐CoV‐2. JAMA 2020; 323: 2249. 10.1001/jama.2020.8259 - DOI - PubMed
  15.  
    1. Colonna C, Monzani NA, Rocchi A et al. Chilblain‐like lesions in children following suspected COVID‐19 infection. Pediatr Dermatol 2020; 37: 437–40. - PMC - PubMed
  16.  
    1. Andina D, Noguera‐Morel L, Bascuas‐Arribas M et al. Chilblains in children in the setting of COVID‐19 pandemic. Pediatr Dermatol 2020; 37: 406–11. - PMC - PubMed
  17.  
    1. El Hachem M, Diociaiuti A, Concato C et al. 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. J Eur Acad Dermatol Venereol 2020. 10.1111/jdv.16682 - DOI - PMC - PubMed
  18.  
    1. Torrelo A, Andina D, Santonja C et al. Erythema multiforme‐like lesions in children and COVID‐19. Pediatr Dermatol 2020; 37: 442–6. - PMC - PubMed
  19.  
    1. Hubiche T, Cardot‐Leccia N, Le Duff F et al. Chilblains appear as a manifestation of SARS‐CoV‐2 infection and reveal features of type I interferonopathy and micro‐vasculopathy (in press). Preprint available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3586683 (accessed 26 August 2020).
  20.  
    1. Kamali Aghdam M, Jafari N, Eftekhari K. Novel coronavirus in a 15‐day‐old neonate with clinical signs of sepsis, a case report. Infect Dis (Lond) 2020; 52: 427–9. - PMC - PubMed
  21.  
    1. Cordoro KM, Reynolds SD, Wattier R, Mccalmont TH. Clustered cases of acral perniosis: clinical features, histopathology and relationship to COVID‐19. Pediatr Dermatol 2020; 37: 419–23. - PMC - PubMed
  22.  
    1. Xing Q, Li G, Xing Y et al. Precautions are needed for COVID‐19 patients with coinfection of common respiratory pathogens. MedRxiv 2020. 10.1101/2020.02.29.2002769 - DOI
  23.  
    1. Wölfel R, Corman VM, Guggemos W et al. Virological assessment of hospitalized patients with COVID‐19. Nature 2020; 581: 465–9. - PubMed
  24.  
    1. Patrick DM, Petric M, Skowronski DM et al. An outbreak of human coronavirus OC43 infection and serological cross‐reactivity with SARS coronavirus. Can J Infect Dis Med Microbiol 2006; 17: 330–6. - PMC - PubMed
  25.  
    1. Lv H, Wu NC, Tsang OT et al. Cross‐reactive antibody response between SARS‐CoV‐2 and SARS‐CoV infections. Cell Rep 2020; 31: 107725. - PubMed
  26.  
    1. Grifoni A, Weiskopf D, Ramirez SI et al. Targets of T cell responses to SARS‐CoV‐2 coronavirus in humans with COVID‐19 disease and unexposed individuals. Cell 2020; 181: 1489–501.e15. - PMC - PubMed
  27.  
    1. Jääskeläinen AJ, Kekäläinen E, Kallio‐Kokko H et al. Evaluation of commercial and automated SARS‐CoV‐2 IgG and IgA ELISAs using coronavirus disease (COVID‐19) patient samples. Euro Surveill 2020; 25: 2000603. - PMC - PubMed
  28.  
    1. Connors JM, Levy JH. COVID‐19 and its implications for thrombosis and anticoagulation. Blood 2020; 135: 2033–40. - PMC - PubMed
  29.  
    1. Bialynicki‐Birula R, Siemasz I, Otlewska A et al. Influence of COVID‐19 pandemic on hospitalizations at the tertiary dermatology department in south‐west Poland. Dermatol Ther 2020: e13738. 10.1111/dth.13738 - DOI - PMC - PubMed
  30.  
    1. Patrizi A, Bardazzi F, Filippi F et al. The COVID‐19 outbreak in Italy: preventive and protective measures adopted by the Dermatology Unit of Bologna University Hospital. Dermatol Ther 2020; 33: e13469. 10.1111/dth.13469 - DOI - PMC - PubMed
  31.  
    1. Atzori L, Mugheddu C, Addis G et al. Psoriasis health care in the time of the coronavirus pandemic: insights from dedicated centers in Sardinia (Italy). J Eur Acad Dermatol Venereol 2020; 34: e247–8. - PMC - PubMed
  32.  
    1. Temiz SA, Dursun R, Daye M, Ataseven A. Evaluation of dermatology consultations in the era of COVID‐19. Dermatol Ther 2020; 33: e13642. 10.1111/dth.13642 - DOI - PMC - PubMed
  33.  
    1. Reynolds SD, Mathur AN, Chiu YE et al. Systemic immunosuppressive therapy for inflammatory skin diseases in children: expert consensus‐based guidance for clinical decision‐making during the COVID‐19 pandemic. Pediatr Dermatol 2020; 37: 424–4. - PubMed
  34.  
    1. Wollenberg A, Flohr C, Simon D et al. European Task Force on Atopic Dermatitis (ETFAD) statement on severe acute respiratory syndrome coronavirus 2 (SARS‐Cov‐2)‐infection and atopic dermatitis. J Eur Acad Dermatol Venereol 2020; 34: e241–2. - PubMed
  35.  
    1. Ricardo JW, Lipner SR. Considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the COVID‐19 pandemic. Dermatol Ther 2020: e13687. 10.1111/dth.13687 - DOI - PMC - PubMed
  36.  
    1. Shah M, Sachdeva M, Alavi A et al. Optimizing care for atopic dermatitis patients during COVID‐19 pandemic. J Am Acad Dermatol 2020; 83: e165–7. - PMC - PubMed
  37.  
    1. Mahil SK, Yiu ZZN, Mason KJ et al. Global reporting of cases of COVID‐19 in psoriasis and atopic dermatitis: an opportunity to inform care during a pandemic. Br J Dermatol 2020; 183: 404–6. 10.1111/bjd.19161 - DOI - PMC - PubMed
  38.  
    1. Abdollahimajd F, Shahidi‐Dadras M, Robati RM, Dadkhahfar S. Management of pemphigus in COVID‐19 pandemic era; a review article. Arch Acad Emerg Med 2020; 8: e51. - PMC - PubMed
  39.  
    1. Di Altobrando A, Patrizi A, Bardazzi F. Should SARS‐CoV‐2 influence immunosuppressive therapy for autoimmune blistering diseases? J Eur Acad Dermatol Venereol 2020; 34: e295–7. - PMC - PubMed
  40.  
    1. Wang C, Rademaker M, Baker C, Foley P. COVID‐19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: an Australian/New Zealand consensus statement. Australas J Dermatol 2020; 61: 210–16. - PMC - PubMed
  41.  
    1. Kasperkiewicz M, Schmidt E, Fairley JA et al. Expert recommendations for the management of autoimmune bullous diseases during the COVID‐19 pandemic. J Eur Acad Dermatol Venereol 2020; 34: e302–3. 10.1111/jdv.16525 - DOI - PMC - PubMed
  42.  
    1. Garcovich S, Bersani FS, Chiricozzi A, De Simone C. Mass quarantine measures in the time of COVID‐19 pandemic: psychosocial implications for chronic skin conditions and a call for qualitative studies. J Eur Acad Dermatol Venereol 2020; 34: e293–4. 10.1111/jdv.16535 - DOI - PMC - PubMed
  43.  
    1. Marasca C, Ruggiero A, Napolitano M et al. May COVID‐19 outbreaks lead to a worsening of skin chronic inflammatory conditions? Med Hypotheses 2020; 34: e302–3. - PMC - PubMed
  44.  
    1. Chen P, Zhang G, Zhan Y. Management strategies of autoimmune bullous diseases during the outbreak of novel coronavirus disease (COVID‐19). J Dermatolog Treat 2019: 1–2. 10.1080/09546634.2020.1771261 - DOI - PubMed
  45.  
    1. Brunasso AMG, Massone C. Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid‐19 emergency in a tertiary center in Italy. Dermatol Ther 2020; 33: e13495. 10.1111/dth.13695 - DOI - PMC - PubMed
  46.  
    1. Radi G, Simonetti O, Diotallevi F et al. How can I take care of you? The dermatologist meets patients' needs during the Covid19 pandemic. Dermatol Ther 2020; 33: e13740. 10.1111/dth.13740 - DOI - PMC - PubMed
  47.  
    1. Jakhar D, Kaur I, Kaul S. Art of performing dermoscopy during the times of coronavirus disease (COVID‐19): simple change in approach can save the day!. J Eur Acad Dermatol Venereol 2020; 34: e242–4. 10.1111/jdv.16412 - DOI - PubMed
  48.  
    1. Devrim I, Byram N. Infection control practices in children during COVID‐19 pandemic: differences from adults. Am J Infect Control 2020; 48: 933–9. - PMC - PubMed
  49.  
    1. Chen Y, Pradhan S, Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus? J Am Acad Dermatol 2020; 82: 1034. - PMC - PubMed
  50.  
    1. Riphagen S, Gomez X, Gonzalez‐Martinez C et al. Hyperinflammatory shock in children during COVID‐19 pandemic. Lancet (Lond) Engl 2020; 39: 1607–8. - PMC - PubMed
  51.  
    1. Cabrero‐Hernández M, García‐Salido A, Leoz‐Gordillo I et al. Severe SARS‐CoV‐2 infection in children with suspected acute abdomen: a case series from a tertiary hospital in Spain. Pediatr Infect Dis J 2020; 39: e195–8. - PubMed
  52.  
    1. Cheng HY, Jian SW, Liu DP et al. Contact tracing assessment of COVID‐19 transmission dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Intern Med 2020; 180: 1156. 10.1001/jamainternmed.2020.2020 - DOI - PMC - PubMed
  53.  
    1. Liu Y, Yan LM, Wan L et al. Viral dynamics in mild and severe cases of COVID‐19. Lancet Infect Dis 2020; 20: 656–7. - PMC - PubMed
  54.  
    1. Fahmy DH, El‐Amawy HS, El‐Samongy MA et al. COVID‐19 and dermatology: a comprehensive guide for dermatologists. J Eur Acad Dermatol Venereol 2020; 34: 1388–94. - PMC - PubMed
  55.  
    1. Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: a useful tool to fight COVID‐19. J Dermatolog Treat 2020; 31: 325. - PubMed
  56.  
    1. Fox SE, Akmatbekov A, Harbert JL et al. Pulmonary and cardiac pathology in African American patients with COVID‐19: an autopsy series from New Orleans. Lancet Respir Med 2020; 8: 681–6. - PMC - PubMed
  57.  
    1. Colmenero I, Santonja C, Alonso‐Riano M et al. SARS‐COV‐2 endothelial infection causes COVID‐19 chilblains: histopathological, immunohistochemical and ultrastructural study of 7 paediatric patients. Br J Dermatol 2020; 183: 729–37. 10.1111/bjd.19491 - DOI - PMC - PubMed
  58.  
    1. Young S, Fernandez AP. Skin manifestations of COVID‐19. Cleve Clin J Med 2020. 10.3949/ccjm.87a.ccc031 - DOI - PubMed
  59.  
    1. Andina D, Colmenero I, Santonja C. Suspected COVID‐19‐related reticulated purpura of the soles in an infant. Pediatr Dermatol. 2020; 10.1111/pde.14409 - DOI - PubMed

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