Giant Urticaria and Acral Peeling in a Child with Coronavirus Disease 2019.

A healthy 6-year-old girl presented with pruritic skin eruptions. The child was on the sixth day of isolation, with her mother suffering from a mild form of coronavirus disease 2019 (COVID-19) with ageusia and a single febrile episode.

The next day, the child developed fever and pharyngodynia. In the emergency department, a nasal swab for severe acute respiratory syndrome coronavirus 2 (both molecular and antigen tests) was positive, and she was admitted to the COVID-19 unit of our institute.

Skin examination revealed fleeting urticarial lesions lasting <24 hours and migrant appearance with polycyclic contours consistent with the diagnosis of acute viral giant urticaria (Figure, A-C). Two days after the onset of the skin lesions, a desquamation of the distal phalanges of the hands and feet appeared with cyanosis of the apical portion of the nail bed (Figure, D).

Figure

Giant urticaria. A-C, Fleeting orticarioid lesions with polycyclic contours. D, Desquamation of the distal phalanges of the hands.

The remaining physical examination and blood tests were unremarkable. No cardiac or respiratory abnormalities or signs suggestive of Kawasaki disease were evident. An oropharyngeal swab permitted us to rule out a streptococcal infection.

The patient's fever disappeared quickly, lasting only 24 hours. Antihistamine therapy was given for symptomatic relief, with resolution of skin symptoms within 4 days. Mother and child were discharged in good general condition and continued isolation at home.

Several clinical cases of suspected COVID-19 with skin involvement have been described in pediatric age, but most of them were unconfirmed cases.1, 2, 3, 4 The presence of acral peeling, not yet clearly described as a sign of COVID-19, in association with giant urticaria, should be emphasized in our confirmed pediatric case. Moreover, the skin manifestation was the first presenting sign of COVID-19, before the onset of fever. This must be taken into consideration to recognize a pediatric COVID-19 case early.