key: cord-0954122-cx5z7uf7
authors: de Masson, Adèle; Bouaziz, Jean-David; Sulimovic, Luc; Cassius, Charles; Jachiet, Marie; Ionescu, Marius-Anton; Rybojad, Michel; Bagot, Martine; Duong, Tu-Anh
title: Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France
date: 2020-05-04
journal: Journal of the American Academy of Dermatology
DOI: 10.1016/j.jaad.2020.04.161
sha: a062cf8daedaa4fce168ae1422dc3fa969bd8bcb
doc_id: 954122
cord_uid: cx5z7uf7

nan

Coronavirus disease 19 (COVID-19), a pneumonia associated with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2), was first identified in Wuhan, China in December 2019, and was characterized as a pandemic by the World Health Organization (WHO) on March 11, 2020. Fever, dry cough, dyspnea, fatigue, anorexia, ageusia and anosmia are common symptoms of COVID-19. Reported skin manifestations of COVID-19 include erythematous lesions, sometimes with dengue-like petechiae (1), and urticaria and chickenpox-like vesicles (2) . We performed a retrospective observational nationwide study of skin lesions encountered during the COVID-19 pandemic in France from March 18 th to April 9 th , 2020 in an outpatient setting of French private practices. Patients gave informed consent for the publication of their photographs. Two hundred seventy-seven patients were enrolled, half of them were men, median age was 27 years (range, 2-98). The lesions were classified into six categories: urticarial (n=26, 9%, Figure 1A ), vesicular (n=41, 15%, Figure 1B) , acral (n=142, 80%, Figure 1C ), morbilliform (n=25, 9%, Figure   1D -E), petechial (n=7, 3%), livedo reticularis (n=4, 1%) and other (n=41, 15%). Some patients presented with cutaneous signs fitting in multiple categories (detailed in Table 1 ).

Acral lesions were unexpectedly common (n=142). Chilblain-like lesions were the most frequent of the acral lesions (n=106/142, 75%, Figure 1C Table 1 ) and/or reported a close contact with a COVID-19 patient. Additionally, 59 patients had isolated chilblains (without any past history of chilblains and in the absence of cold exposure), without associated extracutaneous symptoms, which may suggest cutaneous symptoms of COVID-19, since this finding has been found in some patients with a positive SARS-Cov2 PCR test in our case series and in two recently published case reports (3, 4) . Histological examination of 3 chilblain-like lesions showed a lichenoid dermatitis with a perivascular and eccrine mononuclear infiltrate, and vascular microthrombi in 2 cases. Due to the retrospective, outpatient setting, and the limited number of available SARS-Cov2 PCR tests in France to date, most patients were not tested. However, the number of observed chilblain-like lesions, in patients without significant past medical history, is extremely unusual during the spring season in France, especially as people are staying inside, and may suggest a link with COVID-19. Finally, the presence of microthrombi in chilblain patients is consistent with the altered coagulation status observed in severe COVID-19 patients (5) . Although the number of tested patients does not allow us to draw firm conclusions regarding a direct link between SARS-Cov2 and these skin lesions, the unexpected outbreak of acral skin lesions in this epidemic context requires further investigation. 

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Acknowledgments: The authors thank all the dermatologists of the French Union of Dermatologists and Venereologists SNDV, general practitioners, pediatricians, who provided data and pictures, and the patients involved in this study.