Acral findings during the COVID-19 outbreak: Chilblain-like lesions should be preferred to acroischemic lesions

To the Editor: We read with great interest the recent paper by Fernandez-Nieto et al¹ published in JAAD. The authors report a case series of acute acroischemic lesions affecting 132 nonhospitalized patients during the coronavirus disease 2019 (COVID-19) outbreak. The same cutaneous findings have been described all over the world, including a preliminary study that we conducted.²

In their article, Fernandez-Nieto et al¹ repeatedly use the appellative “acroischemic” for this cutaneous manifestation. Moreover, they hypothesize a relationship between a COVID-19–related altered coagulation profile and these acral lesions. As the authors state, true ischemic lesions have been reported in severely ill patients with proven coronavirus infection.³

Although the comparison between acral lesions in asymptomatic patients and ischemic lesions in severe cases is important, we find the term “acute acroischemic lesions” not accurate. Patients present with painful or itchy erythematous-edematous lesions of the extremities, sometimes evolving to blistering. This presentation is similar to what it is commonly seen in chilblains. The word “chilblains” itself etymologically refers to cold exposure (chill = cold, blain = sore). The term chilblain-like lesions, in our opinion, therefore would be preferable for the lesions that present in these patients rather than acroischemic lesions. In addition, histopathology of these lesions is quite similar to chilblains, with an absence of true necrosis; this is different to what is typically found in hospitalized patients.⁴

Although the exact pathogenesis of this cutaneous sign is not known yet, a worldwide common nomenclature would in our opinion be a good starting point to avoid confusion among clinicians.