Letter to the Editor
Comment on “Pityriasis rosea in a COVID-19 Pediatric Patient”
Comentario sobre «Pitiriasis rosada en un paciente pediátrico de COVID-19»
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"apellidos" => "Ciccarese" "email" => array:1 [ 0 => "giuliaciccarese@libero.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Drago" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Parodi" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Dermatology Unit, Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "DI.S.Sal., Section of Dermatology, University of Genoa, Genoa, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentario sobre «Pitiriasis rosada en un paciente pediátrico de COVID-19»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The article on pityriasis rosea (PR) in a Coronavirus disease 2019 (COVID-19) pediatric patient by Öncü INS et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> recently published in your journal prompted us to make some observations and describe our experience. The authors correctly state that PR is associated with HHV-6 and/or HHV-7 systemic reactivation<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but include in the PR pathogenesis also autoimmunity, psychogenic factors, vaccines and drugs without making any distinctions between PR and PR-like eruptions<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. In fact, though is true that different factors, including autoimmunity, psychogenic factors, vaccines and drugs may cause HHV-6/7 systemic reactivation and thereby indirectly cause the onset of PR, actually, vaccines and drugs are mostly involved in causing PR-like eruptions<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>. We fully agree with the authors that during COVID-19 pandemic, the diagnosis of PR has become more common<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and after the introduction of the COVID-19 vaccinations also the diagnosis of PR-like eruptions has increased<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient described by Öncü INS et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> received a diagnosis of PR but, regrettably, several peculiar features of the disease have not been reported. The authors did not mention the possible presence of the herald patch and of oropharyngeal lesions<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>, the latter common in children<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, nor systemic/local symptoms that can justify the treatment with betamethasone valerate ointment, 10% urea and cetirizine. Indeed, to date, no treatment is recommended on the basis of evidence-based medicine since PR is a self-limiting exanthemous disease that needs just reassurance and rest<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Low-dosage antiviral treatment with acyclovir should be considered only in cases of extensive, relapsing/persistent PR with associated systemic symptoms to shorten the course of the disease<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>; moreover, in pregnancy PR may herald a possible human herpesvirus (HHV)-6/7 intrauterine fetal infection with premature delivery and fetal death. More specifically, the PR onset before week 15, the presence of enanthem and the involvement of >50% of the body are risk factors for negative pregnancy outcome and, in such cases, appropriate antiviral therapy may be considered<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Unfortunately, the patient described by Öncü INS et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> did not perform serology and polymerase chain reaction (PCR) in serum for HHV-6/7 DNA nor for SARS-CoV-2 RNA. These investigations would have been useful to clarify the possible role of SARS-CoV-2 in the pathogenesis of PR associated with COVID-19. In fact, SARS-CoV-2 may play a role as a trans-activating agent, triggering HHV-6 and/or HHV-7 reactivation and causing, thereby indirectly, the onset of PR<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>, as the authors hypothesized<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. We therefore strongly recommend that these tests be carried out in patients with PR developing in the setting of Covid-19.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Histopathology of the lesional skin biopsy, (that should be numbered in the article as Figure 2)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> really shows extravasated red blood cells in the dermis, that is quite typical of PR, but that the authors incorrectly described as “perivascular erythocyte infiltration”<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Lastly, the defined “COVID-19 infection” should be changed more properly with “SARS-CoV-2 infection”.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pityriasis rosea in a confirmed COVID-19 pediatric patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I.N.S. Öncü" 1 => "D. Güler" 2 => "G. Gürel" 3 => "G.Ş. 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Parodi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000489879" "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "2018" "volumen" => "234" "paginaInicial" => "31" "paginaFinal" => "36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29936509" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SARS-CoV-2 as possible inducer of viral reactivations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Ciccarese" 1 => "A. Parodi" 2 => "F. 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