Table 3.
Studies evaluating the appearance of erythema multiforme (EM) and other acral lesions in pediatric patients affected by COVID-19 (excluding multisystem inflammatory syndrome in children, MIS-C)
| Author, year | Lesion type | n (M) | Age | RT-PCR on oro-/nasopharyngeal swab or endotracheal aspirate (total; positive) | Serology (Y/N, n) | RT-PCR on biopsy (Y/N, n) | Electronic microscopy, histology | SARS-CoV-2 detection (Y/N; n) | Dermatological lesion description | Latency between symptoms (SARS-CoV-2 infection) and the appearance of skin lesions | Other symptoms (type, n) | Dermatological lesion treatment | Follow-up and outcome of skin lesions |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Andina et al. 2021 [33] | acral purpura | 1 (0) | 2 m | 1; 0 | N | N/A (SARS-CoV-2 spike protein at immunohistochemistry) | Dilated superficial dermal vessels lined by swollen endothelial cells; significant red cell extravasation | Y; 1 | Reticulated purpura on both soles | 3 w | Nasal congestion | None | Regression after 2 w |
| Andina-Martinez et al. Pediatr Dermatol 2021 [34] | acral peeling | 6 (4) | 5–13 y | 3; 3 | N | N/A | N/A | Y; 5 (2/6 antigenic test; 1/6 symptoms and household contact) | Peeling of fingertips and toe, mild erythema | 3–21 d | Headache (2), fever (2), cough (2), GI (1), anosmia (1), dysgeusia (1), myalgia (1) | None | Regression |
| Hubiche et al. 2021 [18] | Acral lesions (chilblain 79.6%, EM 2.9% and others) | 103 (55) | mean 11.1 ± 5.2 y—median 13 (8–15) y | 18; 0 | 14; 2 (IgG + , IgM-) | N/A |
5/103; direct immunofluorescence: IgM deposition; histology: dermal perivascular lymphocytic infiltrate, spongiosis, keratinocyte necrosis, eosinophils, mucin deposition, basal layer vacuolization |
Y; 2 (66/103 household contact) | Chilblain, vesicles, palmar/plantar erythema, purpura, acrocyanosis, teleangectasia, acral edema, EM, papules | N/A | N/A | N/A | 71/103 1-m follow-up: 35/71 total recovery, 25/71 partially regressed, 8/71 stable, 2/71 worsened |
| Janah et al. 2020 [35] | EM | 1 (1) | 17 y | N/A | N | N/A | N/A | Y | Erythematous maculopapular atypical targetoid eruption of palms | 15 d | Mild COVID-19 | N/A | N/A |
| Klimach et al. 2020 [36] | Acral erythematous eruption | 1 (1) | 13 y | 1; 1 | N | N/A | N/A | Y | 1-cm erythematous papules on plantar surface and erythematous macules + petechiae in distal lower extremities | Concomitant | Flu-like symptoms | N/A | resolution in 10–14 d |
| Kumar et al. 2021 [37] | Acral purpura | 1 (1) | 13 y | 1; 1 | N | N/A | No IgA deposits (excludes HSP); superficial epidermal necrosis with intraepidermal pustules and small vessel neutrophilic vasculitis | Y | Palpable purpuric-petechial rash on both feet spreading to ankles and lower legs (HSP excluded by histology) | 4 w | None | None | Slow improvement—still some lesions after 4 w |
| Labè et al. 2020 [38] | EM | 1 (1) | 6 y | 1; 1 | N | N/A | N/A | Y | Targetoid elements on cheek, hands and feet | N/A | Fever, painful cheilitis, conjunctivitis | N/A | Discharged in 2 w |
| Ozsurekci et al. 2021 [39] | Acral edema | 22 (15) | median 12 y (range 0–17) | 22; 22 | N | N/A | N/A | Y | acral oedema 2/22, rash 1/22, conjunctivitis 1/22 | NA | Severe COVID-19 infection | None | N/A |
| Rotulo et al. 2021 [40] | Acral peeling, urticaria | 1 (0) | 6 y | 1; 1 | N | N/A | N/A | Y | giant urticaria and acral peeling | 1 d before (urticaria) and 2 d after (acral peeling) | fever, sore throat | antihistamines for symptomatic relief | resolution in 4 d |
| Torrelo et al. 2020 [41] | EM | 4 (3) | 11–17 y | 4; 1 | N | N/A 2/4 (SARS-CoV-2 spike protein at immunohistochemistry)) | 2/4 histology: deep perivascular and perieccrine infiltrate; absence of necrosis of keratinocytes | Y; 3 | EM—4/4 associated pseudo-chilblains | N/A | Respiratory or GI symptoms, itch, pain | 1/4 oral CS, 1/4 topical CS, 2/4 none | Complete recovery in 1–3 w |
| Wolf et al. 2021 [42] | Beau lines | 2 (NA) | 2 and 5 y | 2; 2 | N | N/A | N/A | Y | Beau lines of all fingernails | 3 w | Fever, GI | None | Complete regression after 4 m |
Legend to table: CS corticosteroids, d days, EM erythema multiforme, GI gastrointestinal, HSP Henoch-Schonlein purpura, m months, MIS-C multisystem inflammatory syndrome in children, N no, N/A, not available, w weeks, y years, Y yes