key: cord-0686557-8ugcp9hb
authors: Moghadam, P.; Frumholtz, L.; Jaume, L.; De Masson, A.; Jachiet, M.; Begon, E.; Sulimovic, L.; Petit, A.; Bachelez, H.; Bagot, M.; Bouaziz, J.‐D.; Cassius, C.
title: Frequency of relapse and persistent cutaneous symptoms after a first episode of chilblain‐like lesion during the COVID‐19 pandemic
date: 2021-06-19
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17393
sha: feec25fccb192d4a7506de9d003f527a3268654d
doc_id: 686557
cord_uid: 8ugcp9hb

Chilblain-like lesions (CLL) have been extensively reported during Coronavirus Disease-19 (COVID-19) pandemic in March-April 2020.1 While the link between these lesions and Severe Acute Respiratory Coronavirus 2 (SARS-Cov-2) is still unclear2 , emerging evidences of "long COVID", with extra cutaneous COVID-19 symptoms persisting over 60 days, are reported.3 The aim of this study was to assess the evolution of the CLL overtime. We performed a retrospective study to evaluate the frequency and the characteristics of CLL relapses and the persistence of other cutaneous symptoms. In January 2021, a survey was sent to 132 patients who were addressed to the dermatology department of Saint-Louis hospital, Paris between March 1st and April 30th 2020 for CLL lesions. Ninety-five answers were obtained.

Dear Editor, Chilblain-like lesions (CLL) have been extensively reported during coronavirus disease-19 (COVID-19) pandemic in March-April 2020. 1 While the link between these lesions and severe acute respiratory coronavirus 2 (SARS-CoV-2) is still unclear, 2 emerging evidence of 'long COVID', with extra-cutaneous COVID-19 symptoms persisting over 60 days, is reported. 3 The aim of this study was to assess the evolution of the CLL overtime. We performed a retrospective study to evaluate the frequency and the characteristics of CLL relapses and the persistence of other cutaneous symptoms. In January 2021, a survey was sent to 132 patients who were addressed to the dermatology department of Saint-Louis hospital, Paris between 1 March and 30 April 2020 for CLL lesions. Ninety-five answers were obtained.

Features of the initial CLL episode are presented in Table 1 . It involved the feet in 85 cases (89%), with a median severity of 6 and a median duration of 20 days. Fifty-two patients (55%) had at least one relapse, of which 46 (89%) relapsed after 1 October 2020 (Fig. 1a) . Among them, 37 (71%) had one new relapse, 12 (23%) had two and 3 (6%) had more than three. Global duration and severity of the relapses were stable (Fig. 1b) .

The first CLL relapse appeared after a median remission duration of 7.2 months (IQR 6-8), 11 patients (21%) had a contact with COVID-19-positive patients or suggestive general symptoms and one patient had a positive nasopharyngeal RT-PCR out of 13 (8%). Only eleven patients (21%) changed their lifestyle before the CLL relapse (eight lockdowns, two increased physical activity and one hallux valgus surgery). During the 2nd, 3rd and 4th relapses, respectively, 2/15 (13%), 1/3 and 1/3 patients had suggestive general symptoms, and all the RT-PCRs were negative (n = 4).

In January 2021, 27 patients (28%) had persistent extra-cutaneous symptoms (mainly asthenia, joint pain, myalgia, anxiety, concentration disorder, shortening of the breath) and 64 (67%) had persistent cutaneous symptoms other than CLL (acral paraesthesia, acrocyanosis, erythermalgia, Raynaud phenomenon, livedo). There was a significant association between persistent COVID-19 extra-cutaneous symptoms and persistent cutaneous symptoms (P < 0.05).

The association of CLL outbreak with SARS-CoV-2 is supported by growing evidence. 4, 5 The positivity of RT-PCR and serological tests in our cohort is low and comparable with published data. 6 This can be explained by an insufficient test material during the initial peak of COVID-19, a different immune response not involving antibodies or a too early serological testing. 7, 8 First, assuming that our patients were infected by SARS-CoV-2, we demonstrate a high prevalence of disabling persistent extra-cutaneous and cutaneous symptoms, classifying them as 'extra-cutaneous long COVID' in 28% and 'cutaneous long COVID' in 67% of cases.

Then, we illustrate that 55% of patients who experienced CLL during the first COVID-19 wave relapsed during follow-up. Most patients relapsed during the second wave. We cannot exclude new viral exposure although the majority had neither COVID-19 symptoms nor viral contact. The role of sedentary lifestyle recently discussed is also unlikely as 79% of the patients did not change their lifestyle before the first relapse and the second lockdown in Paris (started on 30 October 2020), was much less limiting than the first lockdown (started on 17 March 2020). 9 Vascular damages which have been reported during COVID-19 10 may repeatedly flare with external factors such as cold weather, explaining the persistent cutaneous symptoms and the relapses. Our study has some limitations related to its self-reporting and retrospective nature. Our data emphasize that a majority of patients, who experienced CLL during the first wave of COVID-19 pandemic, developed relapsing CLL with or without other persistent cutaneous manifestations.

The study was performed in accordance with the principles outlined in the Declaration of Helsinki and all patients have given their informed consent to participate in this study. 

Chilblains is a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France

Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients

Persistent symptoms in patients after acute COVID-19

Clinical, laboratory, and interferon-alpha response characteristics of patients with chilblain-lik-lesions during the COVID-19 pandemic

Type I interferon signature in chailblain-Like lesions associated with the COVID-19 pandemic

Most chilblains observed during the COVID-19 outbreak occur in patients who are negative for COVID-19 on polymerase chain reaction and serology testing

A chilblain epidemic during the COVID-19 pandemic. A sign of natural resistance to SARS-CoV-2 ?

Long COVID in the skin: a registry analysis of COVID-19 dermatological duration

Evaluation of chilblains as a manifestation of the COVID-19 pandemic

Vascular skin symptoms in COVID-19: a French observational study