10.5826/dpc.1301a52
Introduction: SARS-CoV-2 infection is associated with different cutaneous manifestations, including chilblain-like lesions (“COVID-19 toes”), more frequently observed in younger patients. During the current COVID-19 pandemic, pediatric teledermatology has increased considerably since it allows to assist even children quarantined or living in distant geographic locations, also reducing long waiting times. Nonetheless, the correct clinical interpretation of skin lesions suspicious for being related to COVID19 represent a challenge for the dermatologist; in fact, many cutaneous diseases of both infectious and non-infectious origin, like pool palms (also known as “juvenile palmar dermatitis of swimming pools”), can simulate COVID-19 toes.
Objectives: to report a telemedicine-assisted experience on outpatient pediatric cases affected by acral dermatitis during the current COVID-19 outbreak, highlighting a possible underdiagnosed differential diagnosis.
Methods: We included 6pediatric cases, affected by acral acute dermatitis, for which, due to the ongoing pandemic, it was impracticable to conduct a face-to-face visit. We collected clinical data and high resolution images of skin lesions, which were independently examined by three different dermatologists.
Results: We described the first three pediatric cases of pool palms reported in the COVID-era, comparing the clinical characteristics of three other pediatric patients affected by COVID-19 toes. We also performed a literature review of all pool palms cases published to date. Conclusions: Our real-life experience highlights the crucial rule of teledermatology during the ongoing pandemic. Furthermore, the paper emphasizes its criticalities, mainly related to the difficult collection of anamnestic data.
text/xml
2160-9381
2507
en
Paola Savoia
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
teledermatology
Telemedicine Evaluation Of Pediatric Acral Dermatitis In COVID-19 Era: A Real-Life Experience On COVID-19 Toes Versus Pool Palms And Review Of The Literature On Juvenile Palmar Dermatitis 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-01-31
2022-04-21
2023-01-31
2023-03-10
e2023052
Dermatol Pract Concept
Introduction: SARS-CoV-2 infection is associated with different cutaneous manifestations, including chilblain-like lesions (“COVID-19 toes”), more frequently observed in younger patients. During the current COVID-19 pandemic, pediatric teledermatology has increased considerably since it allows to assist even children quarantined or living in distant geographic locations, also reducing long waiting times. Nonetheless, the correct clinical interpretation of skin lesions suspicious for being related to COVID19 represent a challenge for the dermatologist; in fact, many cutaneous diseases of both infectious and non-infectious origin, like pool palms (also known as “juvenile palmar dermatitis of swimming pools”), can simulate COVID-19 toes.
Objectives: to report a telemedicine-assisted experience on outpatient pediatric cases affected by acral dermatitis during the current COVID-19 outbreak, highlighting a possible underdiagnosed differential diagnosis.
Methods: We included 6pediatric cases, affected by acral acute dermatitis, for which, due to the ongoing pandemic, it was impracticable to conduct a face-to-face visit. We collected clinical data and high resolution images of skin lesions, which were independently examined by three different dermatologists.
Results: We described the first three pediatric cases of pool palms reported in the COVID-era, comparing the clinical characteristics of three other pediatric patients affected by COVID-19 toes. We also performed a literature review of all pool palms cases published to date. Conclusions: Our real-life experience highlights the crucial rule of teledermatology during the ongoing pandemic. Furthermore, the paper emphasizes its criticalities, mainly related to the difficult collection of anamnestic data.
Paola Savoia
2023/01/31
10.5826/dpc.1301a52
e2023052
Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
2160-9381
teledermatology
en
e2023052
Wong LC, Rogers M. Pool palms. Pediatr Dermatol. 2007;24(1):95. doi: 10.1111/j.1525-1470.2007.00347.x.
Telemedicine Evaluation Of Pediatric Acral Dermatitis In COVID-19 Era: A Real-Life Experience On COVID-19 Toes Versus Pool Palms And Review Of The Literature On Juvenile Palmar Dermatitis 
https://dpcj.org/index.php/dpc/article/download/2507/1922
     Telemedicine Evaluation of Pediatric Acral
 Dermatitis in COVID-19 Era: A Real-Life Experience
  on COVID-19 Toes Versus Pool Palms and Review
  of the Literature on Juvenile Palmar Dermatitis
        Laura Cristina Gironi1, Andrea Guala2, Francesca Zottarelli1, Francesca Graziola1,
               Elisa Zavattaro1, Elia Esposto1, Giovanni Damiani3,4, Paola Savoia5


1 AOU Maggiore della Carità di Novara, Novara, Italy
2 Department of Pediatrics, Castelli Hospital, Verbania, Italy
3 Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
4 Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
5 Department of Health Sciences, University of Eastern Piedmont, Novara, Italy



Key words: acral dermatitis, COVID-19, COVID-19 toes, pool palms, teledermatology
Citation: Gironi LC, Guala A, Zottarelli F, et al. Telemedicine evaluation of pediatric acral dermatitis in COVID-19 era: a real life
experience on COVID-19 toes versus Pool palms and review of the literature on juvenile palmar dermatitis. Dermatol Pract Concept.
2023;13(1):e2023052. DOI: https://doi.org/10.5826/dpc.1301a52
Accepted: April 24, 2022; Published: January 2023
Copyright: ©2023 Gironi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding Author: Laura Cristina Gironi, AOU Maggiore della Carità, c.so Mazzini 18, 28100 Novara, Italy.
Phone: +39 03213733269. Fax: +39 03213733117. E-mail address: gironi.laura@gmail.com ORCID ID: 0000-0002-7298-4446




Introduction                                                            skin examination; skin lesions images were independently an-
                                                                        alyzed by three different dermatologists (GLC, ZE, GF).
Pediatric acral dermatitis represents a diagnostic challenge,
as it can have various origins [1], including SARS-CoV-2 in-
fection [2], that can cause acro-ischemic lesions, also called
                                                                        Cases Presentation
pseudo-chilblain or pernio-like lesions, or “COVID toe”.
Due to the mild systemic symptoms, the role of dermatolo-               Case 1: a 6-year-old boy with asymptomatic and symmetri-
gists is fundamental in the early recognition of the infection          cal shiny erythematous-edematous plaques on the toe pads
and the consequent pandemic containment [2].                            and the fingertips of both hands (Figure 1, A-E). The child
    We described our real-life experience with teledermatology          had no signs or symptoms and frequented a private pool.
management of 6 pediatric acral dermatites during the first                  Case 2: a 13-year-old girl with partially exulcerated
COVID-19 pandemic. Telemedicine-assisted consultations                  ­erythematous-edematous plaques on the toes, fingertips and
were conducted to collect anamnestic history and perform                palms (Figure 1, F-G). Lesions were mildly painful, bilateral



Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052                                                                           1
Figure 1. Clinical aspect of Case 1 (A-E, 6-year-old child) and 2 (F-G, 13-year-old girl): redness and edema symmetrically involving the pal-
mar (A,B,F) and plantar (C,D,E,G) surface of all the distal phalanges of the feet and hands, with the sole exception of the fifth toe; the palms
of the hands and feet, in correspondence with the metacarpophalangeal and metatarsophalangeal joints, are also partially affected in case 1.
Vesicle-bullous evolution is possible in areas subject to friction on rough pool surfaces (G). Clinical aspect of Case 3 (H-L, 13- and 15-year-
old girls) and 4 (M-O, 3-year-old girl): Chilblain‐like edematous and erythematous lesions involving the feet, on the dorsal surface (H-I-L), or
both on the palmar-plantar and dorsal side (M-N-O). Note the presence of exulcerations on the third and fourth toes (H, L).




2                                                                             Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052
and symmetric. The girl attended the family private pool,                  skin   lesions, subsequently         confirmed      by    laboratory
with a 12 years-old cousin who showed identical lesions.                   investigations.
    Case 3: two 13- and 15-year-old girls, with chilblain‐like                 PM is a benign acquired acral dermatosis, typically
burning-aching edematous and erythematous lesions asym-                    occurring during childhood (mean age of 6.4 years) [3],
metrically involving the feet, that completely resolved in                 probably frequently misdiagnosed with bilateral and sym-
about 3 weeks.                                                             metrical hand involvement. Table 1 reviews all the 15 PM
    Case 4: a 3-year-old girl with bilateral and asymmetri-                cases published [3-6]. PM is characterized by erythematous-­
cal, painful and burning erythemato‐violaceous and edem-                   edematous violaceous asymptomatic lesions with a smooth
atous macules involving the toes and fingers, both on the                  surface, generally non-infiltrated; in some cases, a painful
palmar-plantar and dorsal side (Figure 1, M-O) without sys-                vesicular-bullous evolution has been described [3-5].
temic symptoms.                                                                This mechanical dermatosis is caused by repeated rubbing
    SARS-CoV-2 IgG antibodies were positive in both cases                  of the palmar and/or plantar skin with the hard and rough walls
3 and 4.                                                                   of the swimming pool. Consequently, the convex areas of the
    All 3 dermatologists agreed on the diagnosis of Pool                   palmar and plantar surface are more affected [3-5]. It is mostly
palms (PM), also named “juvenile palmar dermatitis of                      seen in subjects who are learning to swim and so who tend to
swimming pools” in cases 1 and 2. Otherwise, in cases 3                    cling to the pool walls. The dermatosis typically is self-limiting
and 4 all dermatologists hypothesized COVID-19-related                     with the interruption of exposure to the pool environment [3-5].




      Table 1. Clinical findings of all reported PM cases, since the first description, dated in 1992*
                                                                       Anatomical Sites                                     Geographical
             Reference                        Age, Sex                    Involved                    Symptoms                 Origin
 Morgado-Carrasco et al. 2019           5-year-old, F             Palmar surface of the            Painful lesions       Spain
 PMID: 31921496                                                   fingers**
 Novoa et al. 2016                      5-year-old, F             Palmar surface of the            Asymptomatic          Spain
 PMID: 26424817                                                   fingers**                        lesions
                                        4-year-old, F             Plantar surface of the
                                                                  fingers, toe pads and
                                                                  heels**
 Martin JM et al. 2009                  6-year-old, F             Palm and palmar surface          Asymptomatic          Spain
 PMID: 19709557                                                   of the fingers**                 lesions
 Lopez-Neyra et al. 2009                6-year-old, M             Palmar surface of the            Asymptomatic          Spain
 PMID: 19951653                                                   fingers**                        lesions
 Wong et al. 2007                       5-year-old, F             Palmar and plantar               Not specified         Australia
 PMID: 17300665                                                   surface of the fingers**
 Sassolas et al. 1996                   10-year-old, M            Palmar surface of the            Painful lesions       France
 PMID: 9033728                          8-year-old, M             fingers and palms and
                                                                  toe pads**
                                        4-year-old, M
 Lacour et al. 1995                     6-year-old, M             Palmar surface of the            Not specified         France
 PMID: 8687057                          4-year-old, F             fingers and palms**              Asymptomatic
                                                                                                   lesions
 Blauvelt et al. 1992                   12-year-old, F            Palmar surface of the            Asymptomatic          U.S.A.
 PMID: 1619059                          11-year-old, F            fingers and palms**              lesions
                                        3 ½-year-old, M
                                        Age not specified, M

Notes: * We performed a systematic review in MEDLINE using the following keywords: “Pool palms”, “juvenile palmar dermatitis of swim-
ming pools” and “dermatite palmaire juvenile des piscines”. Every reference cited in all the articles included has also been verified. Every arti-
cle that met the search criteria was analyzed, regardless of language (English, Italian, Spanish and French). Gray literature, any document that
hasn’t gone through peer review for a publication and conference abstracts were excluded. **lesions present bilaterally and symmetrically




Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052                                                                                   3
                                                                                     Pre-
          Pool                                Childhood                                                                 COVID-
         palms                                                                   adolescence
                                            (mean 7.1 yrs)                                                              19 toes
                                                                                (mean 13.5 yrs)




                                                                                     Mild
       Simmetric                             No systemic                           systemic                           Asimmetric
                                             symptoms                             symptoms




     Hands and/or                            Skin lesions
      feet, palmo-                             mostly                           Pain or itch in                      Toes and feet,
     plantar surface                        asymptomatic                        75% of cases                         dorsal surface



Figure 2. Diagnostic algorithm for the differential diagnosis between Pool palms and COVID-19 toes dermatoses.




Conclusions                                                             2. Molaee H, Emadi SN, M'Imunya JMN, Davoudi-Monfared E,
                                                                           Mohammed A, Razavi Z. Chilblain or Perniosis-like Skin Le-
In the pre-COVID-19 era, allergic contact dermatitis and                   sions in children during the COVID-19 pandemic: A Systematic
                                                                           Review of Articles. Dermatol Ther. 2022 Jan 3:e15298. doi:
atopic pulpitis were the main differential diagnoses sug-
                                                                           10.1111/dth.15298.
gested by several authors [3]. We report the first PM cases             3. Morgado-Carrasco D, Feola H, Vargas-Mora P. Pool Palms.
reported during the COVID-19 pandemic, proposing a possi-                  Dermatol Pract Concept. 2019;10(1):e2020009. doi: 10.5826
ble potentially underestimated differential diagnosis among                /dpc.1001a09.
childhood acral dermatosis. PM may indeed present clinical              4. Martín JM, Martín JM, Ricart JM. Lesiones eritematov-
features like the acral lesions observed in mild COVID-19                  ioláceas en las palmas. Diagnóstico: Palmas de piscina
                                                                           [­Erythematous-violaceous lesions on the palms]. Actas Dermo-
patients; nevertheless, an accurate clinical and anamnestic
                                                                           sifiliogr. 2009;100(6):507-8. PMID: 19709557
evaluation can properly orient clinicians (Figure 2).                   5. Novoa A, Klear S. Pool palms. Arch Dis Child. 2016;101(1):41.
                                                                           doi: 10.1136/archdischild-2015-309633.
                                                                        6. Wong LC, Rogers M. Pool palms. Pediatr Dermatol.
References                                                                 2007;24(1):95. doi: 10.1111/j.1525-1470.2007.00347.x.
 1. Caccavale S, Ruocco E. Acral manifestations of systemic diseases:
    Drug-induced and infectious diseases. Clin Dermatol. 2017
    Jan-Feb;35(1):55-63. doi: 10.1016/j.clindermatol.2016.09.008.




4                                                                          Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052
