LAUSR

Dear Editor Skin manifestations of SARS-CoV-2 infection have recently been a major topic in dermatology, and more lesion patterns are being described as time goes by and knowledge of this entity increases. Papular acrodermatitis of childhood (PAC) is a well-defined reactive dermatosis that usually sets during childhood, and is presumably caused by a virus-induced immune response. Epstein–Barr and hepatitis B viruses are the most frequently related, and more recently, similar eruptions have been reported in association with SARS-CoV-2 infection. While vaccination against different pathogens is a wellrecognized cause of PAC, this condition usually affects pediatric patients. Diphtheria, polio, tetanus, pertussis, hepatitis A and B, Japanese encephalitis and measles vaccines have all been described as possible PAC triggers. After the onset of SARS-CoV-2 vaccination programs, skinrelated side reactions are expected to appear as population immunization progresses. We report two cases of PAC-like eruption after SARS-CoV-2 immunization using the Pfizer-BioNTech vaccine in two young males. The first patient was a 23-year-old man with no medical history of interest who consulted for presenting asymptomatic skin lesions in both hands, elbows, and feet, all of which had suddenly appeared 3 days after SARS-CoV-2 vaccination. Physical examination revealed the presence of multiple erythematous papules and plaques located in the back and palm of the hands, and similar lesions coalescing in both elbows (Figure 1A,B). Chilblain-like and purpuric lesions were observed in the toes (Figure 1C,D). Lesions were treated successfully with topical betamethasone applied twice a day, and no recurrences were observed after receiving the second dose of the vaccine, which was not contraindicated due to the low intensity of the dermatologic process. The second patient was another 23-year-old man, with a history of chronic suppurative otitis media, who developed similar skin lesions affecting both hands, elbows, knees, and feet (Figure 1E,H), 13 days after receiving the second dose of SARS-CoV-2 vaccination. No reagudization of his otologic process was registered in the previous months, and no potential triggers other than the immunization were detected. The same treatment with topical betamethasone was indicated, and lesions disappeared within a few days. In both cases, we investigated the presence of other potential triggers of a PAC-like eruption through guided anamnesis and microbiological studies, including specific polymerase chain reaction tests for herpes virus family, and serologies for hepatitis A, B, C and E viruses, human immunodeficiency virus (VIH), syphilis, mycoplasma, enterovirus, and parvovirus B19, all resulting negative. In the first case, an underlying autoimmune disorder was studied owing to the morphology of the feet lesions. Blood analyses including