Chilblain‐like lesions on feet and hands during the COVID‐19 Pandemic
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The clinical presentation widely referenced is fever, cough, headache, myalgia, asthenia, anosmia, and diarrhea1, 2; but few dermatological findings associated with the virus have been described to date.3-5
Over recent days, a series of cases in Spain have begun to emerge noted by many dermatologists. Amongst them is a group to which the authors belong called Teledermasolidaria. This group of dermatologists has been treating urgent cases from home via an application made available by the Spanish Academy of Dermatology and Venereology (AEDV).
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Our cohort of six patients presented with multiple skin lesions, especially on the toes, soles, fingers, extremities and/or heel similar to chilblains as shown in Figs. 1–5-1–5 and Table 1. Our patients were asymptomatic without coronavirus symptoms. Very few referred cough, fever, or congestion 3‐4 weeks before and some had risky contacts. Two of the patients had a positive test weeks before.
|Age/sex||Chilblain location/symptoms||COVID‐19 positive||Symptoms of COVID‐19,||Close contact to COVID‐19||Time in weeks during/prior/after COVID‐19|
|1||15/M||Toes, heel/ mild itchy||
|Asymptomatic||No||Unknown: skin lesions led to the diagnosis of pneumonia, otherwise asymptomatic.|
|2||15/F||Finger, heel/ mildly painful when pressing||Test not done||Nasal congestion, diarrhea||Father with COVID‐19, close contact||One week prior mild symptoms and 3 weeks after visiting her father|
|3||23/F||Toes/mild itchy||Test not done||Fever, headaches, itchy||Lives in high risk area||3 weeks prior|
|4||44/M||Toe/mildly painful when pressing||Test not done||Sore throat||Unknown||Sore throat 10 days earlier|
|5||91/M||Toe||Yes (requiring hospitalization)||Recovered||After 3 weeks of COVID‐19 confirmed|
|6||24/F||Toes/painful when pressing||Yes||After infection|
An asthmatic 15‐year‐old male patient consulted in the Emergency Department for multiple skin lesions (five in toes and heels; Fig. 1a–c). The patient was otherwise asymptomatic. Because of an awareness of this type of lesion, a chest x‐ray was performed showing mild bilateral pneumonia. The patient was treated with hydroxychloroquine, azithromycin, and prophylactic heparin with resolution of the lung opacities. Surprisingly, polymerase chain reaction (PCR) and rapid antibody test were negative.
A 15‐year‐old female presented with lesions in fingers and heels 3 weeks after visiting her father who had COVID‐19. She was living with him until he became ill and consequently was admitted to the hospital after testing positive for COVID‐19. She had nasal congestion and mild diarrhea 1 week before the skin lesions appeared. Similar to the other patients, the lesions initially were reddish and palpable (Fig. 2a) and 1 week later became purpuric (Fig. 2b).
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Similar lesions and news about the same type of injuries in teenagers and young people have appeared simultaneously in other countries (Italy and France), which are at a similar moment in the curve of the epidemic.6, 7
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It has also been discussed in dermatology forums whether these lesions are histologically translating vasculitis or the presence of microthrombi. Acro‐ischemia has been described in critical COVID‐19 patients in the context of possible hypercoagulation status.8 Similarly, digital ischemia has been described as a complication of influenza, probably in relation to immunological mechanisms and the activation of a prothrombotic state.9 These published cases differ from our presented patients as they are in the context of an acute infection with criteria of severity and findings of cutaneous ischemia in adult patients. Purpuric skin lesions have also been described in children in the context of other viral infections. Although parvovirus is perhaps the virus most involved in purpuric lesions, we would like to highlight a published case of acute hemorrhagic edema of infancy due to a different coronavirus (NL63).10
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It is interesting that cutaneous lesions have also been described in animals (particularly in cats) in coronavirus infections and that they have been more frequent in young animals and in late stages of the disease. In these cases, the lesions are different presenting as nodular pyodermatitis but in the biopsies vasculitis and necrosis have been described.11
Our impressions are only hypothetical so confirmation is needed. Our proposal is that, until it can be confirmed, when faced with these type of lesions we need to explore possible contacts with COVID‐19, and in every case inquire about the existence of fever or cold in the weeks prior to the appearance of the skin lesions. Likewise, these lesions could help the diagnosis in patients who are otherwise asymptomatic. In fact, it is considered that between 20–78% of cases could be asymptomatic,12 which would be consistent with our series if the hypothesis is confirmed. Furthermore, it would be of great interest to perform the reverse transcription polymerase chain reaction (RT‐PCR) test and IgM ‐IgG serological test in these patients.
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We wish to express our appreciation to Dr. Cristina Galván for leading the immeasurable study on skin lesions and COVID‐19 in Spain, as well as Dr. Rosa Taberner for her reputable blog (blog dermapixel) where one may find further information regarding this problem, and all my colleagues on the “dermachat” forum. Finally, Dr. Pablo Fonda is to be commended for his excellent and inspiring initiative, Teledermasolidaria. We also want to show our condolences for the deceased and their families.
- 1, , . The novel coronavirus originating in Wuhan, China. JAMA 2020; 323(8): 709. 2亿元注资能否拯救中宇卫浴？ 恢复客户信心是难题
- 2, , , et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497– 506.
- 3. Cutaneous manifestations in COVID‐19: a first perspective. J Eur Acad Dermatol Venereol 2020. [Epub ahead of print]. 1至5月北京商品房销售面积同比下降50.7%
- 4, , , , , . Comment on: cutaneous manifestations in COVID‐19: a first perspective. Safety concerns of clinical images and skin biopsies. J Eur Acad Dermatol Venereol 2020. [Epub ahead of print]. 淄博七成陶企恢复生产 日产量下降厂家开始涨价
- 5, , , , . A distinctive skin rash associated with Coronavirus Disease 2019? J Eur Acad Dermatol Venereol 2020. [Epub ahead of print]. 2015开年经理人信心回落 去库存仍是主要工作
- 6, . Monday's case: acute acro‐ischemia in the child at the time of COVID‐19. Eur J Pediatr Dermatol 2020.
- 7. Covid‐19: les dermatologues appellant à la vigilance sur les acrosyndromes et érythèmes faciaux. Le quotidien du medecin 2020 Apr. Available from: For generations, working-class whites were doubly blessed: they enjoyed privileged status based on race, as well as the fruits of broad economic growth.
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- 8, , , et al. Clinical and coagulation characteristics of 7 patients with critical COVID‐2019 pneumonia and acro‐ischemia. Zhonghua Xue Ye Xue Za Zhi 2020; 41: E006.
- 9, , , . Digital ischemia in a patient with recent influenza A infection. IMAJ 2018; 20: 446– 447.
- 10, , . Acute hemorrhagic edema of infancy after coronavirus infection with recurrent rash. Case Rep Pediatr 2017; 2017: 1– 3.
- 11, . Feline infectious peritonitis in a cat presented because of popular skin lesions. Can Vet J 2019; 60: 183– 185.
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Number of times cited according to CrossRef: 71
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