COVID‐19 lockdown induced acral dermatosis in children

Dear Editor

Recently, several case series of cutaneous acral manifestations in patients with suspected or confirmed coronavirus disease 2019 (COVID‐19) have been reported. ¹ , ² , ³ A majority of these acral manifestations have a pseudo‐chilblain pattern with erythema and oedema and sometimes vesicles.

Indirect consequences of the ongoing pandemic on skin health have been reported, such as an increased frequency of irritant dermatitis related to repeated hand washing with soap, or occupational dermatoses in health care workers due to wearing gloves or masks. ⁴ , ⁵ Furthermore, there have been some concerns that enforcement of strict social isolation measures may be associated with stress‐induced worsening of chronic inflammatory skin diseases such as psoriasis or atopic dermatitis. ⁶

We describe here acral lesions observed in seven children (four girls) by the sixth week of the lockdown period in France. Three cases were observed in one family. All were healthy children aged 5–8 years (mean age 6 years) referred, by paediatricians or orthopaedic surgeons, for teledermatology consultation, for recently acquired rounded pad‐like hyperkeratotic areas on the feet (6/7) (Figs 1a,c,d and 2b,c) and knees (1/7) (Fig. 2a). These asymptomatic lesions were located over the bony prominences of the feet and legs, suggesting a frictional dermatosis. They were initially erythematous and then slightly hyperpigmented. When specifically asked, the parents reported a recent history of prolonged sessions of playing activities on the floor since the lockdown period had begun. The children had tended to sit cross‐legged (Fig. 1b) or lying face down while they were playing.

Figure 1.

Localized rounded areas of skin thickening over bony prominences of the feet with erythema (a, d) or discrete hyperpigmentation (c) in 3 children. Typical playing position, squatting on one leg in a young boy (b) with associated skin damage (d) explained by the rubbing of bare skin on the rough carpet.

Figure 2.

Erythematous (a, b) and hyperpigmented (c) lesions in 2 other children. Patient (a, b) used to play lying down on the carpet, without socks and pants. Note the involvement of knees and dorsal face of the toes.

Extensive home restriction measures adopted worldwide over the last few weeks have had profound implications on families’ daily activities. Young children spend more time playing in unusual positions on the floor at home. Repeated mechanical trauma of the skin may induce localized hyperkeratosis. These lesions have been described as occupational dermatoses on the hands of carpet installers, ⁷ on the feet of professional dancers ⁸ or in Yoga practioners. ⁹ They are sometimes described as ‘chewing‐pads’ on the hands in case of chewing, sucking or manipulating tic‐like habits in children and adolescents. These lesions may also be observed in heavy users of video games. ¹⁰ Pachydermatodactyly is a particular form of repeated trauma‐induced dermatosis of the hands characterized by a cutaneous thickening of the lateral aspects of the fingers with mainly dermal changes and very little epidermal thickening.

Although a larger case series would strengthen our hypothesis, we suggest that the change of daily habits in young children during the lockdown period may have increased the frequency of acral frictional dermatoses that are not directly due to the virus but rather to prolonged sessions spent playing on the floor.

Conflicts of interest

None to declare.

Funding sources

None to declare.