Erythema annulare centrifugum following SARS‐CoV‐2 infection in a pediatric patient

Dear Editor,

As SARS‐CoV‐2 infection continues to affect both the pediatric and adult populations, various cutaneous manifestations of the disease such as erythema multiforme, urticaria, vesicular exanthem, and pediatric inflammatory multisystem syndrome have been reported in the pediatric population. ¹ A rare skin disease, erythema annulare centrifugum (EAC), has also been observed to develop following COVID‐19 infection. ² Herein, we would like to report a unique case of EAC associated with SARS‐CoV‐2 infection in a pediatric patient.

A 10‐year‐old boy was seen in the outpatient dermatology clinic for a rash of 14‐months duration. It started as an erythematous plaque on the anterior chest which gradually expanded outwards with central clearing. The lesion was asymptomatic with no pain or itch. Four weeks prior to the onset of lesions, he was diagnosed with SARS‐CoV‐2 infection, confirmed by real‐time polymerase chain reaction (RT‐PCR). He had mild symptoms of low‐grade fever, myalgia, and runny nose which was treated symptomatically. Physical examination revealed giant annular‐polycyclic plaque with central clearing on the anterior trunk (Fig. 1). Potassium hydroxide examination was negative. Histopathological examination showed acanthosis accompanied by orthokeratosis in the epidermis, perivascular/interstitial dermatitis in the superficial dermis, vacuolar degeneration in the epithelial basal layer, perivascular lymphocytes in the upper dermis, and lymphocyte‐predominant inflammation surrounding the small capillaries in the upper dermis in a coat sleeve pattern (Fig. 2). Clinicopathologic findings were consistent with EAC. Treatment with triamcinolone acetonide 0.1% cream was applied twice daily for 10 days with complete resolution of the lesion.

Figure 1.

Giant annular‐polycyclic plaque with central clearing on the anterior trunk

Figure 2.

Vacuolar degeneration in the epithelial basal layer and predominant inflammation of perivascular lymphocytes in the upper dermis (a) (hematoxylin and eosin, ×200); the lymphocyte‐dominant inflammation surrounding the small capillaries in the upper dermis in a coat sleeve pattern (b) (hematoxylin and eosin, ×400)

EAC is a figurate erythema which reflects a delayed‐type hypersensitivity reaction to various antigens even though most of the cases are idiopathic. ³ Some possible triggering factors are systemic infections, medications, neoplasms, various autoimmune diseases, connective tissue disorders, sarcoidosis, hypereosinophilic syndrome, foods, and other systemic diseases. ³ It begins as an erythematous papule and plaque which expands to the periphery 2–3 mm per day and takes on its characteristic annular appearance. ⁴ A rim of scale is sometimes noted behind the advancing border, called the trailing scale. Although the most common symptom is itching, EAC is often asymptomatic. ⁵

Our case was diagnosed with EAC with clinical and histopathological findings. The short time interval (4 weeks) between the start of the lesion and COVID‐19 diagnosis, supports the relationship between EAC and SARS‐CoV‐2 infection. It has been suggested that tumor necrosis factor‐alpha pathway plays an important role in the etiopathogenesis of EAC. ³ SARS‐CoV‐2 infection may cause immune system dysregulation with the release of pro‐inflammatory cytokines. Therefore, SARS‐CoV‐2 may contribute to the development of EAC. To date, there have been only two cases of EAC which developed following SARS‐CoV‐2. ² , ⁶ The first case is a 35‐year‐old female patient reported from Italy, and the second case is a 37‐year‐old female patient from Spain. ² , ⁶

In conclusion, we report, to our knowledge, the first case of EAC associated with SARS‐CoV‐2 infection in a pediatric patient, which showed complete resolution with topical corticosteroid treatment.

Authors' contributions

Aysel Cakir: Conceptualization; visualization; data curation; writing original draft. Ecem Bostan: Writing/reviewing the original draft. Esin Kaymaz: Conceptualization; visualization; data curation.