COVID-19 in children – cutaneous involvement is common

COVID-19 cases in children are rising and the same appears for the potentially lethal complication of multisystem inflammatory syndrome. Skin lesions such as chilblains may often be present in paediatric cases of COVID-19.

By the end of April 2021, the number of children tested positive for COVID-19 had risen to over 3.78 million – over 13% of all reported cases [1]. “Infections can occur as young as the neonatal period,” said Prof. Elena B. Hawryluk (Massachusetts General Hospital, MA, USA). She also pointed out that children rarely suffer from severe disease and encounter fewer bad outcomes [2]. Children have several distinguishing features compared with adults, leading to generally milder courses of COVID-19: a strong antiviral innate immunity, healthy endothelium, sporadic presence of factors contributing to the risk of severe disease, and fewer receptors for angiotensin-converting enzyme in nose and lung, which may hinder host-cell invasion.

As children often lack the common signs of COVID-19, skin signs can play an important role. “Over 8% of hospitalised children have a cutaneous eruption,” stated Prof. Hawryluk. A rare but grave complication of COVID-19 that may appear in children at a median of 25 days after viral symptoms is called multisystem inflammatory syndrome (MIS-C). By the end of March 2021, the Centers for Disease Control and Prevention (CDC) reported 3,185 cases of MIS-C with 36 fatalities [3]. Criteria for having MIS-C are suspected or confirmed COVID-19, fever of ≥38°C for ≥1 day, the need for hospitalisation, involvement of ≥2 organ systems, and laboratory results confirming inflammation [2,3]. “Skin involvement is common in MIS-C: >50% of cases show mucocutaneous changes which can present with polymorphous rash, distal extremity changes, oral mucous membrane changes, and conjunctivitis,” Prof. Hawryluk summed up [2]. MIS-C can present in 3 different phenotypes: (i) overlapping with either severe acute COVID-19, (ii) Kawasaki disease (KD), and (iii) without overlap of one of these 2 diseases. Black and Hispanic children have the highest risk for MIS-C [4]. For distinguishing children with MIS-C from those with KD, it is important to know that <50% meet the formal criteria of KD. They also tend to be older and gastrointestinal symptoms are more common than in KD. “Fortunately, most MIS-C patients recover,” Prof. Hawryluk highlighted. Nevertheless, MIS-C entails ICU admission rates of 80% and a mortality of about 2% [5].

Of the pernio-like lesions (PLLs) that dermatologists see, around 29% are in children and adolescent COVID-19 patients [2,6]. PLLs present as acral lesions with purpuric of erythematous surfaces on the base of immune mechanisms that could involve interferon [5]. PLLs may be recurrent, normally only last for 1-3 weeks, and are self-limiting [2]. Also, other acral and non-acral skin lesions have been reported in children with COVID-19, but confirmation of the virus in tissue biopsies was not always given. Positive biopsies were found in erythema multiforme-like lesions [7].

“Dermatologists have an important role in containing the pandemic by appropriately counselling patients and testing for acute infection if indicated,” Prof. Hawryluk emphasised in her summary. She encouraged her colleagues to report paediatric presentations to the AAD COVID-19 Dermatology Registry.

1. American Academy of Pediatrics 2021. Retrieved from aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report on 20 May 2021.
2. Hawryluk EB. COVID-19 and pediatric dermatology. Session S028: COVID-19 symposium. AAD VMX 2021, 23-25. April.
3. Centers for Disease Control and Prevention. Retrieved from cdc.gov/mis-c/cases/index.html on 20 May 2021.
4. Yasuhara J, et al. Pediatr Pulmonol. 2021;56(5):837-848.
5. Andina D, et al.Clin Exp Dermatol. 2021;46(3):444-450.
6. Freeman EE, et al. J Am Acad Dermatol. 2020;83(2):486-492.
7. Torello A, et al. Pediatr Dermatol. 2020;37(3):442-446.

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Posted on 7 June, 202115 February, 2024