key: cord-0998290-s8u7yl24
authors: D, Fernandez-Nieto; J, Jimenez-Cauhe; A, Suarez-Valle; OM, Moreno-Arrones; D, Saceda-Corralo; A, Arana-Raja; D, Ortega-Quijano
title: Comment on: “Acral findings during the COVID-19 outbreak: Chilblain-like lesions should be preferred to acro-ischemic lesions”
date: 2020-05-21
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.05.078
sha: 6f8a4a22e034d6db64b6cf485f9f8d67fcb4ad44
doc_id: 998290
cord_uid: s8u7yl24

nan

and Bassi, in which they propose to use the term "chilblain-like lesions" instead of 27 "acro-ischemic lesions" to denominate the acral lesions in COVID-19 patients 1 . At the 28 time of analyzing our study, only two papers reporting "acro-ischemia" in COVID-19 29 patients had been published, and thus we acquired the same name. In the next days, 30 numerous articles were published reporting these acral lesions with different terms, 31

including: chilblain-like lesions, chilblains, pseudo-chilblain, erythema pernio-like, 32 perniosis-like, vascular skin symptoms, vascular acrosyndromes, COVID-19-induced 33 chilblains, or chilblains of lockdown, among others. 34

Dermatology has been traditionally a morphologic and descriptive specialty, and we 35 still use a plethora of ancient names based on morphology of skin lesions. We are prone 36 to create new terms by adding the prefix pseudo-, or the suffix -like to original entities' 37 names. This is usually due either to clinical or histological resemblance to the original 38 entities, or to an incomplete understanding of their pathophysiology 2 . It is true that 39 many of the reported cases are morphologically similar to classical chilblains or pernio. 40 However, several articles from different countries reported acral lesions with little or no 41 resemblance to chilblains, also affecting other areas than just the fingers: yellowish-42 erythematous plaques on the heels, targetoid pink plaques on the dorsum of feet, hands 43 or elbows, swollen and violaceous toes, or acral non-necrotic purpura. We also found in 44 our study a pattern with coalescing macules and vesicles, some of them with targetoid 45 appearance, that do not fit in the classical chilblain description 3 . 46

As Piccolo et al. stated, etymology of the word "chilblains" includes chill-(cold). 47

However, most of the reported cases in COVID-19 times have not been related to cold 48 exposure. Given the suggested alterations in coagulation, endothelial dysfunction and 49 thrombotic response associated with COVID-19 4 , it is not unreasonable to think that 50 similar stimuli (with different intensity) may play a role in these acral lesions both in 51 asymptomatic and hospitalized patients. In fact, a recent French study did find "vascular 52 microthrombi" in two biopsies of non-hospitalized patients with chilblain-like lesions 5 . 53

We believe that acral skin lesions in COVID-19 patients are a continuum ranging from 54 subtle erythematous macules, chilblain-like lesions, to gangrene or digital ischemia. It is 55 possible that multiple etiological factors are involved in the development of COVID-19 56 acral and non-acral skin lesions, including both coagulation disorders and immune 57

We agree that an international etymological consensus should be created to group these 59 skin manifestations, at least until the exact pathogenesis is elucidated. Chilblain-like 60 lesions is the most used term nowadays. It is a morphological term that is better than the 61 etiological term acro-ischemic lesions. However, it is not a perfect term, as it would 62 cover the majority of the skin manifestations, but not all of them. 63 64

Acral findings during the COVID-19 outbreak: Chilblain-67 like lesions should be preferred to acro-ischemic lesions

Pseudo" Nomenclature in Dermatology: What's in a Name

Characterization of 72 acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 73 patients during the COVID-19 outbreak

Coagulation abnormalities and thrombosis in 76 patients with COVID-19

Chilblains are a common 79 cutaneous finding during the COVID-19 pandemic: a retrospective nationwide 80 study from France