Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052 1 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 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 pseudo-chilblain or pernio-like lesions, or “COVID toe”. Due to the mild systemic symptoms, the role of dermatolo- gists is fundamental in the early recognition of the infection and the consequent pandemic containment [2]. We described our real-life experience with teledermatology management of 6 pediatric acral dermatites during the first COVID-19 pandemic. Telemedicine-assisted consultations were conducted to collect anamnestic history and perform skin examination; skin lesions images were independently an- alyzed by three different dermatologists (GLC, ZE, GF). Cases Presentation Case 1: a 6-year-old boy with asymptomatic and symmetri- cal shiny erythematous-edematous plaques on the toe pads and the fingertips of both hands (Figure 1, A-E). The child had no signs or symptoms and frequented a private pool. Case 2: a 13-year-old girl with partially exulcerated erythematous-edematous plaques on the toes, fingertips and palms (Figure 1, F-G). Lesions were mildly painful, bilateral 2 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052 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). Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052 3 and symmetric. The girl attended the family private pool, with a 12 years-old cousin who showed identical lesions. Case 3: two 13- and 15-year-old girls, with chilblain‐like burning-aching edematous and erythematous lesions asym- metrically involving the feet, that completely resolved in about 3 weeks. Case 4: a 3-year-old girl with bilateral and asymmetri- cal, painful and burning erythemato‐violaceous and edem- atous macules involving the toes and fingers, both on the palmar-plantar and dorsal side (Figure 1, M-O) without sys- temic symptoms. SARS-CoV-2 IgG antibodies were positive in both cases 3 and 4. All 3 dermatologists agreed on the diagnosis of Pool palms (PM), also named “juvenile palmar dermatitis of swimming pools” in cases 1 and 2. Otherwise, in cases 3 and 4 all dermatologists hypothesized COVID-19-related skin lesions, subsequently confirmed by laboratory investigations. PM is a benign acquired acral dermatosis, typically occurring during childhood (mean age of 6.4 years) [3], probably frequently misdiagnosed with bilateral and sym- metrical hand involvement. Table 1 reviews all the 15 PM cases published [3-6]. PM is characterized by erythematous- edematous violaceous asymptomatic lesions with a smooth surface, generally non-infiltrated; in some cases, a painful vesicular-bullous evolution has been described [3-5]. This mechanical dermatosis is caused by repeated rubbing of the palmar and/or plantar skin with the hard and rough walls of the swimming pool. Consequently, the convex areas of the palmar and plantar surface are more affected [3-5]. It is mostly seen in subjects who are learning to swim and so who tend to cling to the pool walls. The dermatosis typically is self-limiting 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* Reference Age, Sex Anatomical Sites Involved Symptoms Geographical Origin Morgado-Carrasco et al. 2019 PMID: 31921496 5-year-old, F Palmar surface of the fingers** Painful lesions Spain Novoa et al. 2016 PMID: 26424817 5-year-old, F Palmar surface of the fingers** Asymptomatic lesions Spain 4-year-old, F Plantar surface of the fingers, toe pads and heels** Martin JM et al. 2009 PMID: 19709557 6-year-old, F Palm and palmar surface of the fingers** Asymptomatic lesions Spain Lopez-Neyra et al. 2009 PMID: 19951653 6-year-old, M Palmar surface of the fingers** Asymptomatic lesions Spain Wong et al. 2007 PMID: 17300665 5-year-old, F Palmar and plantar surface of the fingers** Not specified Australia Sassolas et al. 1996 PMID: 9033728 10-year-old, M Palmar surface of the fingers and palms and toe pads** Painful lesions France 8-year-old, M 4-year-old, M Lacour et al. 1995 PMID: 8687057 6-year-old, M Palmar surface of the fingers and palms** Not specified France 4-year-old, F Asymptomatic lesions Blauvelt et al. 1992 PMID: 1619059 12-year-old, F Palmar surface of the fingers and palms** Asymptomatic lesions U.S.A. 11-year-old, F 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 4 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023052 2. Molaee H, Emadi SN, M'Imunya JMN, Davoudi-Monfared E, Mohammed A, Razavi Z. Chilblain or Perniosis-like Skin Le- sions in children during the COVID-19 pandemic: A Systematic Review of Articles. Dermatol Ther. 2022 Jan 3:e15298. doi: 10.1111/dth.15298. 3. Morgado-Carrasco D, Feola H, Vargas-Mora P. Pool Palms. Dermatol Pract Concept. 2019;10(1):e2020009. doi: 10.5826 /dpc.1001a09. 4. Martín JM, Martín JM, Ricart JM. Lesiones eritematov- ioláceas en las palmas. Diagnóstico: Palmas de piscina [ Erythematous-violaceous lesions on the palms]. Actas Dermo- sifiliogr. 2009;100(6):507-8. PMID: 19709557 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. 2007;24(1):95. doi: 10.1111/j.1525-1470.2007.00347.x. Conclusions In the pre-COVID-19 era, allergic contact dermatitis and atopic pulpitis were the main differential diagnoses sug- gested by several authors [3]. We report the first PM cases reported during the COVID-19 pandemic, proposing a possi- ble potentially underestimated differential diagnosis among childhood acral dermatosis. PM may indeed present clinical features like the acral lesions observed in mild COVID-19 patients; nevertheless, an accurate clinical and anamnestic evaluation can properly orient clinicians (Figure 2). References 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. Pool palms Simmetric Hands and/or feet, palmo- plantar surface Childhood (mean 7.1 yrs) No systemic symptoms Skin lesions mostly asymptomatic Pain or itch in 75% of cases COVID- 19 toes Pre- adolescence (mean 13.5 yrs) Mild systemic symptoms Asimmetric Toes and feet, dorsal surface Figure 2. Diagnostic algorithm for the differential diagnosis between Pool palms and COVID-19 toes dermatoses.