Giant Urticaria and Acral Peeling in a Child with COVID-19:
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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 (COVID-19) with ageusia and a single febrile episode. The next day the child developed fever and pharyngodinia. In the emergency room, a nasal swab for SARS-CoV2 (both molecular and antigen tests) was positive, and she was admitted to the COVID-19 Unit.

Skin examination revealed fleeting urticarial lesions lasting less than 24 hours and migrant appearance with polycyclic contours consistent with the diagnosis of acute viral giant urticaria. 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. 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 to rule out a streptococcal infection.

The fever disappeared quickly, lasting only 24 hours. Antihistamine therapy was given for symptomatic relief, with resolution of skin symptoms within four 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. The presence of acral peeling, in association with giant urticaria, should be emphasized in 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.