key: cord-316673-ffkh13xm authors: Andina, David; Noguera‐Morel, Lucero; Bascuas‐Arribas, Marta; Gaitero‐Tristán, Jara; Alonso‐Cadenas, José Antonio; Escalada‐Pellitero, Silvia; Hernández‐Martín, Ángela; de la Torre‐Espi, Mercedes; Colmenero, Isabel; Torrelo, Antonio title: Chilblains in children in the setting of COVID‐19 pandemic date: 2020-05-22 journal: Pediatr Dermatol DOI: 10.1111/pde.14215 sha: doc_id: 316673 cord_uid: ffkh13xm BACKGROUND: Different skin manifestations of COVID‐19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID‐19 pandemic. MATERIAL AND METHODS: A retrospective review of 22 children and adolescents with chilblain‐like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID‐19 in Madrid, Spain. RESULTS: All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D‐dimer results, but without systemic symptoms or other laboratory anomalies. SARS‐CoV‐2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow‐up, all cases showed spontaneous marked improvement or complete healing. CONCLUSION: Acute chilblains were observed during COVID‐19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown. Dermatology ANDINA et Al. A retrospective study was conducted in children and adolescents (up to 18 years of age) presenting to the Emergency Department in a 12day period (April 6-17, 2020) with skin manifestations of chilblains, in the form of erythematous to purpuric macules and violaceous swellings located on the toes, feet, fingers, and hands. Approval from the institutional Ethics Committee and Board was obtained. Standard informed consents were obtained for recording images in all patients and for skin biopsies when considered. We recorded age, sex, personal history of previous diseases, contacts with potentially infected relatives, skin symptoms, type and location of lesions, dermoscopy, systemic symptoms, and therapies administered. Laboratory analyses performed were also recorded, as well SARS-CoV-2 PCR from oropharyngeal and nasopharyngeal swabs. Skin biopsies obtained were processed for light microscopy and stained with hematoxylin and eosin, PAS stain, and colloidal iron. Twenty-two patients (13 male and 9 female), age range 6-17 years (median 12 years), were seen in the Emergency and Dermatology Departments of the Children's University Hospital Niño Jesús in Madrid, Spain, with acrally located erythemato-purpuric lesions consistent with chilblains ( Table 1) . Duration of lesions before consultation ranged from 1 to 28 days (median 7 days). No patient had a history of rheumatic disease, lupus erythematosus, Raynaud's phenomenon, acrocyanosis, or previous history of chilblains. Five of them had a diagnosis of attention deficit hyperactivity disorder (ADHD) and were on treatment with methylphenidate hydrochloride (three cases), methylphenidate hydrochloride, aripiprazole, and intuniv (one case) and lisdexamfetamine (one case) for more than 1 year, with no change in dosage within the last 6 months. Feet were affected in all 22 cases ( Figure 1 ). The typical lesions consisted of acrally located, erythemato-violaceous or purpuric macules on the toes and lateral aspects of the feet and heels. The tips and periungual or distal subungual areas of the toes were commonly involved. In other instances, patients showed swollen toes with dusky, violaceous discoloration. Less frequently, dark ischemic areas with superficial blisters were seen. As lesions evolved, skin hyperpigmentation was observed in follow-up visits. Three patients also showed similar lesions on the fingers, located predominantly on the periungual areas. Dermoscopy was recorded in 10 patients, and the signs observed ( Figure 2 ) included violaceous erythema, dilated capillaries, ischemic areas, purpuric dots, and hyperpigmentation. Pruritus (9, 41%) and mild pain (7, 32%) were present in some cases. Systemic symptoms appeared in 10 patients; they consisted of mild respiratory symptoms (cough and rhinorrhea) in nine patients (41%) and gastrointestinal complaints (abdominal pain and diarrhea) in two patients (9%); one patient presented with both respiratory and gastrointestinal symptoms. These symptoms had appeared corticosteroids were prescribed for one patient and a short course of oral steroids for another case, both for associated erythema multiforme. All cases were first seen in the emergency department, and 21 of them were seen in the dermatology clinic 1-10 days after their initial visit. Then, all 22 cases were contacted on the telephone, except for patients biopsied, who were seen again 7 days later. The lesions showed marked improvement or almost complete resolution 3-5 weeks after their onset. We Chilblains, also called pernio, is a cutaneous localized inflammatory reaction resulting from a maladaptive vascular response to non-freezing cold. 9 It is most common in women and middle-aged adults and seems to be uncommon in children. 9 diseases causing weight reduction. 10, 15, 16 None of these possible etiologies were present in our patients, not even cold exposure, and given the timing, SARS-CoV-2 is felt to be the most likely etiology of chilblains in these patients. Five of our patients were receiving medications for ADHD, and these have been linked to blue toe syndrome and cyanotic peripheral vasculopathy. 17, 18 However, these drug-related conditions run a chronic course and appear at onset or after dose increase of the medications. Our patients were taking these medications for more that 6 months at the same dosage, and all had an acute course of chilblains. A history of a viral illness may occasionally precede chilblains, 10 and cryoproteins, which may be produced after viral illnesses, were detected in four out of the eight cases in a pediatric series over 10 years in Colorado (three with cryoglobulins and one with cold agglutinins). 14 However, cryoproteins are very seldom detected in cases of chilblains. 10 Considering the very high incidence of viral illnesses in children, the incidence of virus-induced chilblains has historically been very low, which is in sharp contrast to the large number of cases collected in our institution in such a short period of time. Severe acral ischemic lesions due to thrombosis have been observed in COVID-19 patients, usually admitted to intensive care units with very severe disease. 6 Cutaneous manifestations in COVID-19: a first perspective A distinctive skin rash associated with Coronavirus Disease Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients Urticarial eruption in COVID-19 infection A dermatologic manifestation of COVID-19: transient livedo reticularis Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia Acute acro-ischemia in the child at the time of COVID-19 Screening and severity of coronavirus disease 2019 (COVID-19) in children in Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic A histologic and immunohistochemical study of chilblains Pernio in pediatrics Case report: sixyear-old girl with recurrent episodes of blue toes Childhood pernio and cryoproteins Chilblains and antiphospholipid antibodies: report of four cases and review of the literature Chilblains accompanying interleukin-1 receptor-associated kinase (IRAK)-4 deficiency Blue toes after stimulant therapy for pediatric attention deficit hyperactivity disorder Methylphenidate and dextroamphetamine-induced peripheral vasculopathy Comparative analysis of chilblain lupus erythematosus and idiopathic perniosis: histopathologic features and immunohistochemistry for CD123 and CD30 Clinical and histopathologic feature sand immunologic variables in patients with severe chilblains. A study of the relationship to lupus erythematosus Cutaneous histopathological findings of Aicardi-Goutières syndrome, overlap with chilblain lupus Insights from mendelian interferonopathies: comparison of CANDLE, SAVI with AGS, monogenic lupus Overly exuberant innate immune response to SARS-CoV-2 infection COVID-19) infection induced chilblains: a case report with histopathological findings. JAAD Case Rep Vasospasm is a consistent finding in pernio (chilblains) and a possible clue to pathogenesis Neurovascular instability syndrome: a unifying term to describe the coexistence of temperature-related vascular disorders in affected patients Epub ahead of print. How to cite this article: Andina D, Noguera-Morel L, Bascuas-Arribas M, et al. Chilblains in children in the setting of COVID-19 pandemic