SLR - November 2020 - Carlyn M. Hinish

Chilblains in Children in the Setting of Covid-19 Pandemic

Reference: Andina, D., Noguera-Morel, L., Bascuas-Arribas, M., Gaitero-Tristán, J., Alonso-Cadenas, J. A., Escalada-Pellitero, S., Hernández-Martín, Á., de la Torre-Espi, M., Colmenero, I., & Torrelo, A. (2020). Chilblains in Children in the Setting of Covid-19 Pandemic. Pediatric dermatology, 37(3), 406–411.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Carlyn M. Hinish, DPM
Residency Program: Central Michigan University Educational Partners – Saginaw, MI

Podiatric Relevance: Since Covid-19 was first described, there have been frequent reports of skin lesions associated with this infection. These lesions have been noted most commonly on the hands and feet. As a newly described disease process, identification of associated lesions is vital for early identification, treatment and isolation of these patients who may be unaware of COVID-19 status. This dematologic process may be an instance where podiatric physicians are the first discoverers of Covid infection in patients. 

Methods: This is a retrospective review of 22 patients aged 6-17 who presented to an Emergency Department in Madrid, Spain over a 12-day period in April 2020. All patients presented with chilblain-like lesions to their lower extremity and were also diagnosed with Covid-19. For each patient age, sex, health history, skin lesion type and location, dermoscopy results, laboratory studies, systemic symptoms and treatments were recorded.  

Results: All 22 patients had clinically and dermatologically diagnosed acute chilblains lesions on their toes with three patients having additional lesions on their fingers. The onset of lesions ranged from one to 28 days after first systemic symptom of Covid-19. Related to these lesions, nine patients had associated pruritus and seven had mild pain. Ten patients had systemic symptoms at the time of their emergency department visit, all were mild including abdominal pain or mild respiratory symptoms. No patients had a history of rheumatic disease or previous history of chilblains. 

All lesions were acrally located erythemato-violaceous or purpuric macules. The most common lesion locations included periungual and subungual areas, as well as the tips of the digits. As lesions evolved, they became hyperpigmented prior to resolution. Dermoscopy was completed on 10 patients and revealed violaceous erythema, dialated capillaries, ischemic areas, purpuric dots and hyperpigmentation. Biopsies were taken of 6 lesions, all of which demonstrated superficial and deep angiocentric and eccrinotropic lymphocytic infiltrate, papillary dermal edema, vacuolar degeneration of the basal layer and lymphocytic exocytosis to the epidermis. 

The only required treatments were oral pain medications and steroids, and these were not required by all patients. After initial evaluation in the emergency department, patients were seen in the dermatology clinic 1-10 days after initial visit. They were also called seven days after their outpatient appointment. All lesions shows marked improvement or nearly complete resolution within three to five days from onset.

Conclusions: Symptoms of acute chilblains is now recognized as an associated symptom seen in some children and adolescents infected by Covid-19. All reviewed cases demonstrated similar clinical appearance, dermoscopic appearance and pathology. This review suggests that these symptoms are often mild and self-limiting. Early identification of these lesions by podiatric physicians may lead to Covid-19 diagnosis. If diagnosis has been previously made, podiatric physicians may monitor these lesions with evidence of resolution pattern and process. 

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