Most Chilblains Observed During the COVID-19 Outbreak Occur in Patients Who Are Negative for COVID-19 on Polymerase Chain Reaction and Serology Testing

L. Le Cleach; L. Dousset; H. Assier; S. Fourati; S. Barbarot; C. Boulard; C. Bourseau Quetier; L. Cambon; C Cazanave; A. Colin; E. Kostrzewa; C. Lesort; A. Levy Roy; F. Lombart; J. Marco-Bonnet; J.-B. Monfort; M. Samimi; M. Tardieu; P. Wolkenstein; E. Sbidian; M. Beylot-Barry


The British Journal of Dermatology. 2020;183(5):866-874. 

In This Article

Abstract and Introduction


Background: Acral lesions, mainly chilblains, are the most frequently reported cutaneous lesions associated with COVID-19. In more than 80% of patients tested, nasopharyngeal swabs were negative on reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 when performed, and serology was generally not performed.

Methods: A national survey was launched on 30 March 2020 by the French Society of Dermatology asking physicians to report cases of skin manifestations in patients with suspected or confirmed COVID-19 by using a standardized questionnaire. We report the results for acral manifestations.

Results: We collected 311 cases of acral manifestations [58.5% women, median age 25.7 years (range 18–39)]. The most frequent clinical presentation (65%) was typical chilblains. In total, 93 cases (30%) showed clinical suspicion of COVID-19, 67 (22%) had only less specific infectious symptoms and 151 (49%) had no clinical signs preceding or during the course of acral lesions. Histology of skin biopsies was consistent with chilblains. Overall, 12 patients showed significant immunological abnormalities. Of the 150 (48%) patients who were tested, 10 patients were positive. Seven of 121 (6%) RT-PCR-tested patients were positive for SARS-CoV-2, and five of 75 (7%) serology-tested patients had IgG anti-SARS-CoV-2. Tested/untested patients or those with/without confirmed COVID-19 did not differ in age, sex, history or acral lesion clinical characteristics.

Conclusions: The results of this survey do not rule out that SARS-CoV-2 could be directly responsible for some cases of chilblains, but we found no evidence of SARS-CoV-2 infection in the large majority of patients with acral lesions during the COVID-19 lockdown period in France.


Coronavirus disease 2019 (COVID-19) is a disease resulting from SARS-CoV-2 infection, which was first reported in Wuhan, China and has subsequently spread to the rest of the world.[1,2] The World Health Organization (WHO) declared a pandemic viral infection on 11 March 2020.

The first cutaneous manifestations were described in mid-March 2020; since then, more than 50 studies reporting more than 1000 cases have been published, mainly from European countries. Cutaneous manifestations possibly associated with COVID-19 are diverse and include different types of exanthema (maculopapular, urticarial and chickenpox-like lesions).[3,4] Acral lesions, mainly chilblains, are the most frequently reported cutaneous manifestation.[3,5] The direct causal link between these skin manifestations and SARS-CoV-2 infection is suspected but remains uncertain.

Acral lesions are mainly observed in adolescents and young adults and are clinically described as pseudochilblains, sometimes with bullous lesions or pseudoerythema multiforme, which are two patterns that can overlap. Lesions resolved spontaneously in 1–4 weeks.[3,6]

Owing to the high number of reported cases, media sources alerted that chilblains are a sign of COVID-19 and that the appearance of such cutaneous manifestations should lead to measures of isolation and COVID-19 testing.

The aim of our study was to describe the clinical characteristics of acral lesions at the time of the COVID-19 outbreak in order to provide evidence of an association or lack of association between SARS-CoV-2 infection and acral manifestations.