key: cord-1004564-rk92zs0d authors: Landa, Nerea; Mendieta‐Eckert, Marta; Fonda‐Pascual, Pablo; Aguirre, Teresa title: Chilblain‐like lesions on feet and hands during the COVID‐19 Pandemic date: 2020-04-24 journal: Int J Dermatol DOI: 10.1111/ijd.14937 sha: 659ce91ff8fb1712dd1c3cb425abb06b0e32b276 doc_id: 1004564 cord_uid: rk92zs0d nan 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). Initially, a series of cases consulted us through our personal mobile phones and sent their photographs to us. Later, the queries increased in number. Most of the patients were children (median 13 years) and young adults (median 31, average 36, range 18-91 years old). The lesions are initially reddish and papular resembling chilblains. Subsequently, in the span of approximately 1 week they become more purpuric and flattened. Finally, they seem to resolve by themselves without requiring any treatment. Patients did not show Raynaud or signs of ischemia. Although there is some referred discomfort or pain when palpated, the skin lesions were not very symptomatic. The majority of patients did not present with coronavirus symptoms and when presented they were mild fever or congestion. Except for the oldest patient (91 years old), none of them presented with significant respiratory condition, and they were generally in good health. Herein we share with the dermatology communities around the world a sample of our private patients with chilblain-like lesions which may be a cutaneous manifestation of COVID-19 so that dermatologists can be aware of these findings. 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 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. 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 admit- A 23-year-old female consulted through mobile phone because of lesions on her toes that were a little itchy. She recalls having fever and headache 3 weeks before the onset of skin lesions. We did not have the possibility to do any test for COVID-19. However, she lives in a high-risk COVID-19 area. A 44-year-old male consulted through mobile phone because of a slightly painful lesion on his toe, especially when touched, that was preceded by sore throat. We were not able to test this patient either. A 91-year-old male from the Primary Care Centre consulted for a cutaneous asymptomatic lesion on his toe. He had been hospitalized because of COVID-19 confirmed by PCR 3 weeks before. We do not know exactly when the skin lesions appeared but he was recovering at home at the time the lesions were noticed by his doctor. A 24-year-old female with lesions on her toes after COVID-19 infection confirmed by PCR. Unfortunately, we have no photographs of her lesions. The lack of confirmatory testing does not allow us to corroborate the association of these type of lesions with COVID-19. Our hypothesis is that these lesions could be a late manifestation of COVID-19. This theory is based on the fact that the lesions appeared weeks after reaching the peak of infections in Spain but not at the beginning so far as we are aware. This is supported by the fact that some of the patients reported compatible symptoms or higher risk contacts (sick persons or health workers) weeks prior to the appearance of skin lesions. We hypothesized that it could be antigen-antibody immunological processes at a time when the viral load and infectivity are low. The fact that the PCR had been negative in some of the patients in which it was performed, could be justified for three reasons: there was no coronavirus infection, false negatives, or that it was really a late manifestation in which PCR had already reversed to negative. 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 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. Until further confirmation that these lesions are related to COVID-19, we must be cautious and recommend general measures of social distance, hygiene, self-isolation, and surveillance. We wish to express our appreciation to Dr. Cristina Galv an 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 The novel coronavirus originating in Wuhan, China Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Cutaneous manifestations in COVID-19: a first perspective Comment on: cutaneous manifestations in COVID-19: a first perspective. Safety concerns of clinical images and skin biopsies A distinctive skin rash associated with Coronavirus Disease Monday's case: acute acro-ischemia in the child at the time of COVID-19 Covid-19: les dermatologues appellant a la vigilance sur les acrosyndromes et eryth emes faciaux. Le quotidien du medecin Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia Digital ischemia in a patient with recent influenza A infection Acute hemorrhagic edema of infancy after coronavirus infection with recurrent rash Feline infectious peritonitis in a cat presented because of popular skin lesions COVID-19: the case for health-care worker screening to prevent hospital transmission