COVID-PERNIOSIS: Characterization of acral lesions in the context of the COVID-19 pandemic in the pediatric population

Principal Investigators

Our rationale

  • During the COVID19 pandemic the number of children and adolescents with skin lesions on their hands and feet have increased.
  • Whereas the majority of these pediatric patients do not have any other symptom of COVID19 and they have had negative PCR results when tested, some of them have been in contact with family members with suspected or confirmed infection.
  • The type of skin lesion, which resemble perniosis, and the significant increase in the number of otherwise healthy children and adolescents with such lesions during the COVID19 pandemic raises the question of whether they could be the result of an effective innate immune response mediated by IFN type 1 against SARS-CoV-2 infection.
  • Alternatively, these lesions could be explained by a state of hypercoagulability or prothrombotic vasculopathy that has already been described in patients with COVID19 infection both in the lungs and in the acral areas.

What are our main questions

  1. How are the skin lesions related to COVID-19 infection? Are they an initial manifestation in the fight against viral infection or are they a late manifestation of the infection?
  2. Should children with acral lesions due to COVID-19 be considered contagious and isolated or could they have developed immunity against the virus once they have developed these lesions?
  3. Is it possible that these patients have an overproduction of IFN type I, which is responsible for the vasculopathy and, on the other hand, acts as a protective factor against serious affectation of the child?
  4. Is it possible that these lesions are produced by a hypercoagulable state that has already been described in patients infected by COVID-19?
  5. How are these children with acral lesions different from patients with clinically evident infection who do not develop them?

Study design

This is a prospective observational single-center study in a population aged 0-18 years. 

The study aims to characterize hand and foot lesions, determine what relationship they may have with COVID-19 infection, and investigate their pathophysiology to better understand the response to infection.

Scientific objectives

  1. Describe the clinical and demographic characteristics of pediatric patients with acral lesions on the hands and feet.
  2. Describe the epidemiological data regarding contact with confirmed or suspected COVID-19 patients.
  3. Estimate the seroprevalence and incidence of SARS-CoV-2 infection in pediatric patients with acral lesions on the hands and feet.
  4. Describe biochemical markers of inflammation in children with acral lesions: D-dimers, ferritin, LDH and reactive protein.
  5. Study whether there are alterations in coagulation or a hypercoagulable state in children with acral lesions: Antiphopholipic An, Prot C and Prot S.
  6. Study the relation of perniosis with confirmed SARS-CoV-2 infection by means of nasopharyngeal PCR , serologic tests and T-specific responses against SARS-CoV-2.
  7. Study the inflammatory response in children with acral lesions:
    1. Study the response to type 1 Interferon.
    2. Study the expression pattern of interleukins: IL-1, IL-6, IFNgamma and TNFalpha.

Cohorts and samples

Study group

  • Children and adolescents (0-18 years old) who consult for skin lesions on hands and feet regardless of whether they have had COVID-19 symptoms or a history of COVID-19 infection.

Patients with any of these skin lesions on their hands and feet are included: erythematous or violaceous plaques, vesicles and bullae on an erythematous base, purpuric papules, edema of the feet and/or hands.

Information and samples collected

  • General physical and dermatological examination with collection of clinical and epidemiological data.
  • Clinical photographs of the lesions.
  • Nasopharyngeal smear or aspirate: SARS-CoV-2 PCR.
  • General analysis including: hemogram, coagulation tests; D-dimers, Klaus fibrinogen, GOT, GPT, LDH, C-reactive Prot and ferritin.
  • RNA sample, serum sample and plasma sample. Analysis of the IFN signature and cytokine pattern, and quantification of the IgG, IgA and IgM antibodies against SARS-CoV-2.
  • PBMCs samples. Analysis of T-cell specific responses against SARS-CoV-2.

Group members