The Italian case series suggests that the chilblain-like lesions seen in adolescents during the COVID-19 pandemic are non-ischemic and are not associated with systemic or localized SARS-CoV-2 infection.
These lesions are “most likely to be benign,” and resolve spontaneously after 2 to 6 weeks, said Valentina Discepolo, MD, PhD of the University of Naples Federico II. Medscape Medical News..
“These do not appear to be symptoms of systemic inflammatory or autoimmune phenomena. In our experience, they were negative in all cases in the series, so SARS-CoV-2 specific molecular or serological. No inspection is required. ” Discepolo.
Research Published online June 10 JAMA network open..
The fallacy of “COVID toes”?
Researchers write that due to the temporary association between the COVID-19 pandemic and the increased number of chilblain-like lesions, some media call it “COVID toes.” However, they say the data on the association with SARS-CoV-2 are controversial.
In this report, Discepolo and colleagues evaluated 17 adolescents with chilblain-like toe lesions during the first wave of a pandemic in Southern Italy.
Currently, there is no evidence of past or local SARS-CoV-2 infection.
Localization around erythematous colored nails
“In our experience, chilblain-like lesions are not a symptom of COVID-19, as evidenced by SARS-CoV2-specific serological and molecular negatives,” Discepolo said. Medscape Medical News..
Lesions were bilaterally distributed in 16 adolescents (94.1%) and heel skin was involved in 7 (41.2%). Ulcers complicated one patient during the active phase of the disease, and desquamation occurred over time in three patients (17.6%). Only two patients (11.8%) had simultaneous finger involvement.
Self-administration therapy included topical antibiotics and / or corticosteroids, disinfectants, and antifungal agents. Systemic antibiotics or corticosteroids were rarely used.
None of the treatments substantially changed the course of the lesion. The period was “very variable”, from 49 to 145 days. However, in the follow-up, all patients were completely resolved.
White rosette, white stripes, red dots
Almost always, the lesions were characterized by a triplet of red dots, white rosettes, and white stripes on a erythematous background, the researchers report.
In more than half (56%) of patients, red dots often manifested as punctate, comma-shaped, congested blood vessels surrounding the rosette in the early stages of the lesion. At a later stage, the red dots were still present, but the rosette had disappeared.
Although found to be inconsistent in inflammatory skin conditions, the researchers say these three signs do not characterize dermoscopy images of perniosis and suggest a clear disease process. ..
Do not blame ischemia, blood clots
Histological analysis revealed “remodeling of the dermal vessels with lobular arrangement, wall thickening, and mild perivascular lymphocyte infiltration,” they said.
Cyanotic lesions and swelling
Punch biopsy of the skin involved showed predominantly endothelial hyperplasia, mild lymphocyte infiltration, and structural destruction of blood vessels without papillary dermal edema or eosinophil or neutrophil infiltration.
Pathology did not reveal ischemic changes in opposition to systemic angiopathy, Farzam Gorouhi, MD, from Kaiser Permanente, South Sacramento Medical Center, California. Linked editorial.. “Therefore, this study provides further evidence for the pattern of thromboembolic properties presented in adolescence during the COVID-19 pandemic.”
Capillary angiography results used to investigate structural changes in the peripheral microcirculation show completely normal or rare dilatation, confirming the lack of systemic inflammatory processes.
“The lack of capillary microscopic features of major angiopathy events in the study by Discepolo et al. Opposes the ischemia of the disease and therefore the symptoms are not associated with systemic ischemia or embolic events. “It shows,” said Gorouhi.
Chilblain-like lesions are one of the most commonly described skin conditions during the COVID-19 pandemic, but their etiology, including the role of SARS-CoV-2, remains elusive, researchers say. Is writing.
They conclude that the findings in this case series do not support an association between lesions and SARS-CoV-2 infection.
They point out that the fact that only three new cases of chilblain-like lesions reported during the pinnacle of the pandemic were reported further corroborate the lack of association with SARS-CoV-2 infection.
In addition, none of these patients tested positive for SARS-CoV-2, and all three cases of the second wave occurred in winter. This suggests that exposure to the cold can cause skin lesions, at least in some cases. Say.
In line with this hypothesis, 7 (41.2%) of the adolescents in this case series relapsed in winter and tested negative for SARS-CoV-2 again.
“The blood vessels that lifestyle changes during the first strict blockade (decreased physical activity, microtrauma from walking barefoot at home) played a role and led genetically sensitive individuals to develop these lesions. We believe it is likely to promote the local inflammatory process promoted by congestion, “Discepolo said. Medscape Medical News..
There was no special funding for this study.Investigator And Gorouhi Declared that there were no associated conflicts of interest.
JAMA network open.. 2021; 4: e2111676, e2111676. Full text, editorial
