key: cord-281875-lq015thu
authors: Daneshjou, Roxana; Rana, Jasmine; Dickman, Meghan; Yost, John Montgomery; Chiou, Albert; Ko, Justin
title: Pernio-like eruption associated with COVID-19 in Skin of Color
date: 2020-07-12
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.07.009
sha: 
doc_id: 281875
cord_uid: lq015thu

nan

Recently, the skin manifestations of SARS-CoV-2 infection have emerged, with reports and series documenting petechial eruptions, transient livedo reticularis, erythematous rashes, urticaria, primary varicella-like like presentations, and pernio-like eruption. [1] [2] [3] [4] [5] The pernio-like eruption, colloquially termed "COVID toes", appears associated with an otherwise asymptomatic or mildly symptomatic disease course. 4, 6, 7 Several case series and case reports have been published with photos documenting the pernio-like eruption associated with COVID-19; however, most published photos have been in individuals with Fitzpatrick skin types (FST) I or II. [3] [4] [5] It is not uncommon for skin disease to be misdiagnosed in patients with skin of color, which can lead to delayed care and management. 8 Given the disparities in dermatological educational resources, we present a series of seven patients with diverse skin types from FST III to V with pernio-like eruptions during the COVID-19 pandemic. 9 Case series Similar to prior reports, the majority of these patients reported no prior COVID-19 associated symptoms or mild, non-specific symptoms that self-resolved without seeing a physician (Table 1) . 10 The age range for these patients was from 25 to 44 and included 4 males and 3 females. At time of presentation to a dermatologist, patients reported having a pernio-like eruption from a range of 2 weeks to 8 weeks. Four patients could definitively pinpoint potential exposures -either through contact with a known COVID-19 positive individual or interactions with high risk environments without personal protective equipment, such as healthcare settings or international travel. None of the patients had a prior history of pernio or prior rheumatologic disease (Table1). Additionally, these patients could not pinpoint cold or damp exposures that may have precipitated their skin findings, since most were sheltering in place indoors. Patients were seen in clinic in Redwood City, California, where average nighttime low and daytime high temperatures were 43-62 degrees Fahrenheit in February, 45-65 degrees Fahrenheit in March, and 46-69 degrees Fahrenheit in April. 11 Patients were generally healthy at the time of presentation. Clinically, patients presented with a range of physical exam findings from erythema and swelling to purpuric and petechial macules, mostly on the toes, but also on the fingers in one case. No other cutaneous findings were reported. Compared to FST I and II findings previously reported in the literature, we note findings on FST III to V may be more subtle. Erythema can appear different in darker skin tones where pink and red hues are often not seen, and these more subtle findings could lead to a delay in diagnosis.

In patients who received a workup, no coagulation or rheumatological abnormalities were found (Table 1) . Five patients had PCR testing at some point -either due to the cutaneous symptoms or known exposure; all were negative. Six patients underwent serological testing for IgG and IgM 2-8 weeks after initial symptoms (Table 1) ; five were negative and one patient tested positive for SARS-CoV-2 IgG antibodies. Patients generally noted improvement with supportive care and topical steroids.

Understanding the link between SARS-CoV-2 and the pernio-like eruption is an ongoing area of study. Multiple case series have likewise noted negative PCR and serologies despite a history of COVID exposure and symptoms. 4, 10 Recently, a pediatric case series of seven patients found immunohistochemical and ultrastructural evidence of SARS-CoV-2 in skin biopsy samples despite negative respiratory PCRs. 12 We postulate that serological negativity could be due to several reasons: 1) these findings are an epiphenomenon not associated with COVID-19 2) serological conversion happens later with milder or asymptomatic disease 3) antibody titers due to mild or asymptomatic disease do not meet the titer cutoff for positivity, as many serological tests have been developed using symptomatic or hospitalized COVID-19 patients as the gold standard 4) mild or asymptomatic disease does not elicit a robust immune response 5) antibodies to a different epitope are being elicited and not measured in current testing. Additional data establishing the causal link between COVID-19 and pernio-like eruption is needed; in order to facilitate understanding of the appearance of these lesions, we present clinical images across diverse skin types. 

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