Jacquet erosive diaper dermatitis in a child with COVID-19

Abstract

Since the start of the COVID-19 pandemic, several reports around the world indicated that the novel coronavirus could be associated with specific dermatologic manifestations. Among earlier articles, encountered features included erythematous maculopapular exanthems, chilblains-like acral skin lesions, vesicular, and urticarial rashes. We describe the first case of Jacquet erosive diaper dermatitis in a 17-month-old girl with a confirmed COVID-19 infection. This article may serve to expand the knowledge of the diverse clinical features of COVID-19 infection, particularly among the pediatric population.

Introduction

In December 2019, a severe acute respiratory syndrome named coronavirus (SARS-CoV-2) emerged from China. Since then, the disease caused by this virus, “coronavirus disease-19” (COVID-19), spread around the world to become a pandemic, causing a worldwide concern. ¹

Recent reports indicate that this novel coronavirus may be associated with specific cutaneous manifestations, particularly among children. While the exact incidence of COVID-19-associated cutaneous manifestations has not been estimated, the reported prevalence of these findings differed globally. In China, the prevalence of COVID-19-associated cutaneous manifestations was reported to be 0.2%. ² The number was higher in India (7.25%) ³ and Italy (20.4%). ⁴ The most common reported cutaneous patterns included erythematous maculopapular exanthems, chilblains-like acral skin lesions, vesicular, and urticarial rashes. Other rashes included eruptive cherry angioma and herpes simplex viral reactivation, vascular rashes such as livedo reticularis or purpura, erythema multiforme-like eruptions, and otherwise unspecified erythematous rashes, which have been also described. ⁵

The mechanisms of cutaneous manifestations of COVID-19 are largely unknown, as the role of SARS-CoV-2 in its pathogenesis is unclear. Among some of the proposed mechanisms that may explain the cutaneous findings linked to COVID-19 are cytokine release syndrome, SARS-CoV-2 RNA-related immune hypersensitivity reaction, formation of microthrombi, and vasculitis. ⁶

Although worldwide reports on the cutaneous manifestations of COVID-19 are increasing, little is known about their mechanisms and patterns. We narrate a case of a 17-month-old girl who presented to our hospital with a 10-day history of febrile watery diarrhea and a unique rash associated with confirmed COVID-19 infection.

Case report

A 17-month-old Saudi girl was known to have end-stage renal disease secondary to congenital nephrotic syndrome, with confirmed genetic testing for Phospholipase C Epsilon 1 (PLCE1) gene mutation consistent with autosomal recessive nephrotic syndrome type 3 (NPHS3). This young girl was in her usual state of health until February 2022 when she was admitted to our hospital with a 10-day history of fever and watery diarrhea without mucous or blood. In tandem with the onset of the symptoms, the child’s parents noticed a new onset of a severely pruritic rash, involving the buttocks and perianal area. Parents reported the use of over-the-counter creams; however, lesions persisted and failed to improve. The child’s parents denied any similar rash in the past.

A complete skin examination revealed multiple punched-out eroded erythematous macules and patches with islands of re-epithelialization and crater-like borders over the buttocks and perianal skin (Figure 1). No other significant findings were noted on physical examination.

Figure 1.

Multiple punched-out eroded erythematous macules and patches with islands of re-epithelialization and crater-like borders over the buttocks and perianal skin of a 17-month-old girl.

A nasopharyngeal swab was sent upon her admission to the hospital for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time polymerase chain reaction (RT-PCR), which came out to be positive. Her mother reported a positive history of recent exposure to a confirmed COVID-19 infected sibling at home.

Skin cultures from the involved diaper area were assessed; however, they returned back all negative for any associated organisms. Based on the history and clinical picture, a diagnosis of Jacquet erosive diaper dermatitis was made. Patient was then started on a low-potency topical corticosteroid, applied twice daily. In addition to frequent diaper changes and application of barrier creams (zinc oxide) following each change. Three weeks later, the patient demonstrated complete clearance of the lesions with only minimal erythema remained.

Discussion

Jacquet erosive diaper dermatitis also known as dermatitis syphiloides posterosiva is a rare and severe variant of diaper dermatitis, infrequently reported in the literature. ⁷ The disease is typically characterized by erythematous and erosive cutaneous lesions with elevated borders in the perirectal and genital areas. Known predisposing factors are fecal and urinary incontinence, accompanied by the presence of detergent remnants in the diaper area. ⁸ Few studies report an association of Jacquet dermatitis with other entities. Rodriguez-Poblador et al. found a case of Jacquet dermatitis from severe diarrhea after extensive colectomy and anastomosis for Hirschsprung disease. ⁹ Rodríguez Cano et al. reported two patients with Hirschsprung disease and severe diarrhea who developed a distinctive diaper dermatitis after delayed ileoanal anastomosis. ¹⁰ To our knowledge, no reports had previously described this rare entity in relation to COVID-19 infection.

A possible explanation of this severe irritant contact dermatitis in our patient was indirectly caused by COVID-19. As is well-known, prolonged wetness of the diaper area leads to a significant increase in skin pH and subsequent activation of fecal enzymes, leading to maceration of the stratum corneum. ¹¹ Prolonged diarrhea secondary to SARS-CoV-2 infection was probably attributed to the development of Jacquet erosive diaper dermatitis.

The role of cutaneous manifestations in COVID-19-infected patients has not been fully explored. As such, it may be challenging to determine the etiology of skin lesions and clarify whether they are caused by the virus itself or induced by the body’s immune system, and if they are virus-specific or not. Given our understanding, this is the first case describing Jacquet erosive diaper dermatitis in a COVID-19-infected patient.

In conclusion, we have described a rare case of Jacquet erosive diaper dermatitis in a child infected with COVID-19. This degree of suspicion may lead to an earlier recognition and thus avoidance of unnecessary investigations. In this light, it should be included in the initial differential diagnosis when evaluating a child with erosive lesions in the diaper area, especially in the setting of COVID-19-associated diarrhea. The primary limitation of this case study is the short duration of follow-up. Since the patient is living outside Riyadh, post-discharge appointments were made virtually. Thereafter, post-treatment figures were not available. Another limitation is the lack of histopathological data. Even though skin biopsy exhibits a large diagnostic value, biopsy in this case was not done since the diagnosis of Jacquet erosive dermatitis can be made clinically.