Chilblains in children in the setting of COVID-19 pandemic

Abstract

Background: Different skin manifestations of COVID-19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID-19 pandemic.

Material and methods: A retrospective review of 22 children and adolescents with chilblain-like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID-19 in Madrid, Spain.

Results: All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D-dimer results, but without systemic symptoms or other laboratory anomalies. SARS-CoV-2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow-up, all cases showed spontaneous marked improvement or complete healing.

Conclusion: Acute chilblains were observed during COVID-19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown.

Keywords: COVID-19; SARS-CoV-2; acral ischemia; chilblain; dermoscopy; pernio; skin.

FIGURE 1

A‐D, Clinical spectrum of chilblains in four patients in the series

FIGURE 2

Dermoscopic features. A, Violaceous erythema, purpuric dots, and subungual hyperpigmentation. B, Erythema, vasodilatation, and purpuric dots

FIGURE 3

A, Dense, superficial, and deep angiocentric and eccrinotropic lymphocytic infiltrate (H&E stain, 10×). B, Papillary dermal edema, vacuolar degeneration of the basal layer and lymphocytic exocytosis. Endothelia of small vessels appear swollen (H&E stain, 20×). C, Intense lymphocytic vascular reaction in dermal vessels (H&E stain, 40×). D, Red cell extravasation and focal thrombosis (arrow) in papillary dermis capillaries (H&E stain, 100×)