Re: Chilblain‐like lesions on feet and hands during the COVID‐19 pandemic

The coronavirus disease 2019 (COVID‐19) viral pandemic has continued to challenge scientists and physicians attempting to understand the breadth of clinical manifestations and potential severity. Not restricted to the respiratory tract, it appears to affect many organ systems other than the lungs. Dermatologists have been on the watch for skin manifestations. Early on, various skin eruptions were reported, but none were considered specific, and some represented a viral exanthema. Somewhat unexpected has been the emerging numbers of chilblain‐like lesions as shown in the six cases presented in this issue, ¹ a newer and possibly more unique challenge for dermatologists. Are these vascular lesions directly related to the virus? Unfortunately, given the lockout, face‐to‐face evaluations and testing for the virus have been limited, hence the lack of biopsies and thorough vascular and coagulopathy workups. None of the chilblain‐like lesions shown in the six patients presented ¹ had a biopsy. However, based on the clinical presentation of the lesions, they are vascular in nature and are most likely related to perniosis or microthrombi, which could include an antiphospholipid syndrome with a lupus anticoagulant ² or others to be determined.

While the dermatologists are reporting this phenomenon, the physicians taking care of patients have also been challenged by the number of strokes and coagulopathies noted by many. ³ , ⁴ , ⁵ The vascular lesions clinically evident in the skin must be related to what is going on systemically. Could these changes also be an early sign of disease in some patients? We advise the physicians who are caring for COVID‐19 patients to examine the hands and feet of their patients, and if at all possible, obtain a biopsy and a thrombophilia panel when needed.

More importantly in today’s climate, if a patient presents with these lesions, they need to firstly be tested for COVID‐19, as this might be a sign of initial viral infection but could also be post‐infection or even represent prolonged infection or a carrier state.

The world is concerned about the infection by and the sequela of COVID‐19. But in reality, it could be an even more robust and morbid virus than initially suspected. Given the wide spectrum from mild to severe disease, one wonders if there are various strains of the virus that are more dangerous than others in terms of creating systemic disease. The possible role of severe thrombotic diathesis in at least some of the patients that die from the virus raises the possibility that these patients may have other risk factors like a lupus anticoagulant ² or other thrombophilic diathesis like disseminated vascular coagulation (DIC).

This is history in the making, only time will tell.