Researchers Find No Sign of Link Between Chilblains, SARS-CoV-2 Infection

By Will Boggs MD

July 01, 2020

NEW YORK (Reuters Health) - Although several adults and children have developed chilblains during the COVID-19 pandemic, two new European case series find no evidence of a causal link.

Chilblains, also known as pernio-like lesions, pseudo-chilblains, and acute acro-ischemia, are a pattern of acral lesions described as erythematous to purple purpuric macules, papules, and/or vesicles. Their temporal association with the COVID-19 pandemic has led some to call it "COVID toes."

In the first case series, Dr. Anne Herman and colleagues from Universite Catholique de Louvain, in Brussels, describe 31 patients generally in good health who presented with purplish red chilblain lesions on toes and/or fingers which appeared one to 30 days before consultation.

Nine of these patients had a history of chilblains, and four had a history of Raynaud syndrome. Their median age was 22 years, and 11 patients were teenagers.

Histopathologic analysis of skin biopsy specimens in 22 patients confirmed the diagnosis of chilblains.

Although 20 patients reported mild symptoms possibly related to COVID-19, RT-PCR analysis did not detect SARS-CoV-2 RNA on nasopharyngeal swabs from any of the patients in this series or in the 22 biopsy samples from the skin lesions, and antibody testing for IgM and IgG was negative for SARS-CoV-2 in all patients, the authors report in JAMA Dermatology.

When subsequently questioned about their lifestyles, all patients reported that they had been working from home or were homeschooled since the beginning of containment measures in Belgium, and most (20/31, 64%) reported decreased physical activity and considerably more time spent in sedentary positions. Moreover, most patients declared that they remained barefoot or in socks most of the day.

"We hypothesize that these skin lesions may be caused by lifestyle changes brought on by containment and lockdown measures," the authors conclude. "Dermatologic lesions, even if increasingly observed during the current pandemic, should be carefully interpreted."

In the second case series, also in JAMA Dermatology, Dr. Ignacio Torres-Navarro of Hospital Universitario y Politecnico La Fe, in Valencia, Spain, and colleagues report the clinical and etiologic features of 20 children and adolescents with new-onset acral inflammatory lesions without an obvious diagnosis of recognizable cause.

Nine of these patients (45%) had a history of Raynaud phenomenon or perniosis and eight had systemic lupus erythematosus (SLE), but none had clinical symptoms suspected to be COVID-19-related.

As in the other case series, the results of serologic and viral testing were negative for SARS-CoV-2 as well as other viruses in all patients.

"The relationship between acral skin disease and COVID-19 has yet to be proven," Dr. Torres-Navarro told Reuters Health by email.

"One recent study found viral particles in histology of this disease (one by electronic microscopy and six or seven others with immunostaining)," he said. "They were not tested for the virus. As the pandemic was so widespread, maybe these two phenomena happened together."

"It is still unclear whether a viral cytopathic process versus a viral reaction pattern or other mechanism is responsible for 'COVID toes,'" write JAMA Dermatology Section Editor Dr. Claudia Hernandez of Rush University Medical Center, in Chicago, and Deputy Editor Dr. Anna L. Bruckner of the University of Colorado School of Medicine and Children's Hospital Colorado, in Aurora, in a linked editorial.

"Conflicting evidence highlights that testing needs to occur in larger numbers and also at different stages of the disease to determine if a low viral load, undetectable with current methods, or the inability to mount an adequate immune response accounts for the negative SARS-CoV-2 test results," they conclude. "Dermatologists must be aware of the protean cutaneous findings that are possibly associated with COVID-19, even if our understanding of their origins remains incomplete."

Dr. Herman did not respond to a request for comments.

SOURCE:, and JAMA Dermatology, online June 25, 2020.


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