Reply to: “Characterization of acute acro-ischemic lesions in non-hospitalized patients: A case series of 132 patients during the COVID-19 outbreak”
Authors: Giuseppe Ruggiero, Fabio Arcangeli, Torello Lotti, Orsola Ametrano, Cosimo Ruggiero, Salvatore Cucchiara, Salvatore Oliva
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We read with interest the article by Fernandez-Nieto et al.1Fernandez-Nieto D. Jimenez-Cauhe J. Suarez-Valle A. et al.Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak.J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar Cutaneous manifestations of coronavirus disease 2019 (COVID-19) are rarely reported. In their letter, Fernandez-Nieto et al1Fernandez-Nieto D. Jimenez-Cauhe J. Suarez-Valle A. et al.Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak.J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar described an increased number of acroischemic lesions in young patients from Spain. Most patients were asymptomatic or mildly symptomatic, and none of them developed COVID-19 pneumonia or any other complication. It is intriguing that in Italy we are observing the same uncommon increase. Italy and Spain are the 2 European countries with the highest incidence of COVID-19.2World Health OrganizationCoronavirus disease 2019 (COVID-19) situation report– 78.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200421-sitrep-92-covid-19.pdf?sfvrsn=38e6b06d_6Date accessed: April 21, 2020Google Scholar In Italy, after the outbreak onset, many general pediatricians reported on our pediatric dermatology network unusual foot injuries similar to chilblains and without any other symptoms. These lesions have never been described with this frequency before, being usually rare. Thus, we circulated a specific online form among members of the Italian Federation of General Pediatricians to verify the possible association between chilblainlike lesions and COVID-19. Fernandez-Nieto et al1Fernandez-Nieto D. Jimenez-Cauhe J. Suarez-Valle A. et al.Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak.J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar applied a different approach by analyzing dermatology consultations for cutaneous lesions. We reached the same results and conclusions for 100 children (Table I). The Spanish authors found 132 cases in 41 days, whereas ours were collected in 10 days. Even in our cohort, lesions were mostly located in the extremities of the limbs, with only 2 cases involving the face. We found a lower rate of systemic symptoms (16% vs 25%), but our population was slightly younger (mean age 12.5 vs 23.4 years), being likely less symptomatic.3Dong Y. Mo X. Hu Y. et al.Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China.Pediatrics. 2020; 145: e20200702Crossref PubMed Scopus (2659) Google Scholar Almost the same number of positive SARS-CoV-2 test results (1 vs 2 patients) was described in both cohorts. Our patient with a positive result also had extracutaneous symptoms (fever and pharyngodynia). He was exposed to subjects with COVID-19 (family members), as were the COVID-19–infected Spanish patients. This confirms that the chance of finding infected children increases if all cohabiting family members are tested after an index case. Indeed, only 11% of patients in our cohort were tested for severe acute respiratory syndrome Coronavirus 2 (Sars-CoV-2) because of the rigid testing policy in Italy. The Spanish group tested only 8%, thus confirming the difficulty in having testing in overwhelmed public health systems.Table ICharacteristic of Spanish and Italian cohortsCharacteristicsSpain, n = 132Italy, n = 100Age, mean (range)19.9 (1-56 y)12.9 (3 mo-17 y)Male sex (%)71 (53.8)64 (64)Cutaneous symptoms (pain, itching, burning, swelling, erythema) (%)NA61 (61)COVID-19 symptoms (%)18 (13.6)16 (16)COVID-19–positive cases (%)2 (1.5)1 (1)Location of skin lesions (%)Hands: 41 (31)Feet: 108 (81.8)Hands: 25 (25)Feet: 75 (75)Duration of skin lesions, mean (range), d8.7 (2-24)Improvement at day 12 = 76%Therapy (%)74 (74) Topical steroids40 Topical antibiotics8 Topical heparin9 Topical antifungal4 Systemic antibioticsNA2 Systemic steroids4 Antihistamines4 Paracetamol6 Gentamicin + betamethasone11 No therapy26 (26)Improvement by day 4 (%) Therapy31 (41.9) No therapy13 (49.9)Improvement by day 8 (%) Therapy43 (58.1) No therapy19 (73.1)Improvement by day 12 (%) Therapy55 (74.3) No therapy21 (80.7)COVID-19, Coronavirus disease 2019; NA, not applicable. Open table in a new tab COVID-19, Coronavirus disease 2019; NA, not applicable. We did not differentiate between chilblainlike and erythema multiforme–like lesions. We observed and collected only lesions appearing as circumscribed erythematous edematous elements with a purplish-red color, which were thus defined as erythema perniolike lesions (Fig 1). A local or systemic therapy was considered in only 74 of 100 cases (74%) (Table I). Up to 80% of patients by day 12 had a favorable outcome regardless of the therapy used. This observation is additional evidence for a COVID-19 etiology. Indeed, it is known that chilblains can be secondary to viral infections. The likelihood of other seasonal non–COVID-19 infections was extremely low because children were having contact only with their family members because of the national lockdown.4Lazzerini M. Barbi E. Apicella A. et al.Delayed access or provision of care in Italy resulting from fear of COVID-19.Lancet Child Adolesc Health. 2020; 4: e10-e11Abstract Full Text Full Text PDF PubMed Scopus (885) Google Scholar We definitively agree with Fernandez-Nieto et al1Fernandez-Nieto D. Jimenez-Cauhe J. Suarez-Valle A. et al.Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak.J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar about the relationship between erythema perniolike acrolocated lesion onset and COVID-19. General pediatricians worldwide should pay attention to skin lesions during the COVID-19 pandemic. We would like to thank the following persons for contributing to data collection: Biasci Paolo (Italian Federation of General Pediatricians President), Doria Mattia (National Secretary for Scientific and Ethical Activities of Italian Federation of General Pediatricians), Alfinito Mario, Amadori Annalisa, Annibali Amedeo, Battistini Alberto, Bellino Antonino, Berti Marina, Bonadies Lucia, Buffone Maria Raffaela, Buono Giovanni Carlo, Campagna Angela, Candio Francesco, Careddu Domenico, Cartiglia Maria Laura, Caruso Vincenzo, Caternolo Maria, Ciampolini Massimo, Cocchiara Cristoforo, Contiguglia Nino, Cortesia Paolo, Costamagna Martina, Cristofanelli Palmina, De Bona Lidia, De Santis Rosamaria, Di Carlo Maria Teresa, Di Stasio Alessandra, Dolceamore Teresa Rita, Ferri Francesca Donatella, Foderi Stefania, Galioto Roberta, Galli Antonella, Gamboni Cosetta, Giacomin Annamaria, Grasso Silvana, Grasso Maria Carmela, Guaraldi Nicola, Gulino Antonino, Hensen Joanne, La Boria Maria Agata, Licordari Amalia, Longhini Federico, Lualdi Rosa, Mariani Danila, Mazzola Maria Pia, Mura Antonella, Napoli Mario, Paolini Paoletti Fabrizia, Piccione Concetta, Quinci Maria, Ravera Brunella, Romano Maria Rosaria, Sacchetti Roberto, Senesi Paolo, Simonelli Anna Rita, Sonaglia Franca, Squazzini Giuseppe, Stanzione Maria, Stramondo Prospero Sergio, Vallati Marina, Zinna Maria Concetta, Zucchi Graziano. Characterization of acute acral skin lesions in nonhospitalized patients: A case series of 132 patients during the COVID-19 outbreakJournal of the American Academy of DermatologyVol. 83Issue 1PreviewTo the Editor: The coronavirus disease 2019 (COVID-19) has been associated with several skin manifestations, including widespread urticaria, erythematous rash, and varicella-like exanthem.1,2 Ischemic and ecchymotic acral lesions have also been described in patients with severe forms of COVID-19 as a manifestation of clotting disorders.3 Coincident with the COVID-19 pandemic, similar acral lesions have being described in healthy young patients.4 However, the clinical implication and relation to COVID-19 remains unclear. Full-Text PDF Comment on "Characterization of acute acro-ischemic lesions in non-hospitalized patients: A case series of 132 patients during the COVID-19 outbreak"Journal of the American Academy of DermatologyVol. 83Issue 3PreviewTo the Editor: We thank Dr. Ruggiero and colleagues1 for their interest in our article. Full-Text PDF