Cutaneous manifestations on feet and hands during the COVID-19 Pandemic

Chilblain-like lesions on fingers, toes and heels might appear in individuals who either had had the disease or came into contact with it a few weeks prior. In children or adults, with or without symptoms.

The COVID-19 pandemic is caused by a novel coronavirus, SARS-CoV-2, isolated in patients with severe pneumonia in China on 30th December 2019, having spread throughout the world since then with 1,703,890 cases diagnosed and 102,897 deaths (as of 11th Abril 2020, Worldmeter).

The clinical presentation widely referenced is fever, cough, headache, myalgia, asthenia, anosmia, diarrhoea; but few dermatological findings associated with the virus have been described to date.

Over recent days, a series of cases in Spain have begun to emerge which I have had access to by volunteering with Teledermasolidaria, a group of dermatologists who have been treating urgent cases from home via an application made available by the Spanish Academy of Dermatology and Venereology (AEDV). These cases presented with either sole or multiple skin lesions on fingers and/or toes, extremities and heel similar to chilblains, and with some curious red patches on the heel. The first cases began to appear a week ago, but in the last two days I have been able to see some 20 to 25 cases which have given me cause for concern.

Most of the patients were children and young people (20 to 35 years old) with these lesions (see photos) which have been appearing over the last two to three weeks. None of the patients presented with clinical respiratory condition nor fever, and they were generally in good health. Although there is some referred discomfort or pain when pressed, the skin lesions were not very symptomatic.

Some patients indicated risk contacts (mother is a primary care doctor or pharmacist). One child indicated a friend with the same cutaneous symptomatology. Another child presented with the appearance of these skin lesions 3-4 weeks after visiting her father who had COVID-19. Yet another child presented with a cold three weeks ago. Another case was from the Primary Care Centre, a 91-year-old patient, tested positive for COVID-19 on 21st March and who had recovered, having been discharged and sent home only to later present with these lesions a few days ago. Some of the patients presented with a fever or a cold 3-4 weeks ago.

These findings have led me to come up with a hypothesis which I am putting forward at this time so that fellow professionals can be better informed when treating these patients. The cutaneous lesions which appear some weeks after being infected with COVID-19 might be mediated by Ag-AC immunological processes, coinciding with low infectivity when the lesions appear in patients who have recovered from the disease 3-4 weeks prior, either with or without symptoms. This hypothesis is also based on the appearance of these skin lesions after the pandemic’s peak in Spain 2-3 weeks ago.

As with all hypotheses, this one will also need to be confirmed and my proposal is that when faced with this type of symptomatology in patients, that we explore possible contacts with COVID-19, and in every case enquire about a possible cold or fever in the weeks prior to the appearance of the skin lesions. Furthermore, it would be of great interest to perform the RT-PCR test and IgM -IgG serological test.

Furthermore, it would also be good that we are dealing with either recovered patients or in the process of recovering from COVID-19 and that neither they, nor any family members or healthcare personnel who have been in contact with them should be worried about either the evolution of the lesions or about their infectivity.

I wish to express my appreciation to Dr. Cristina Galván for leading the immeasurable study on skin lesions and COVID-19 in Spain, as well as Dr. Rosa Taberner for her reputable blog (blog dermapixel) where one may find further information regarding this problem, and all my colleagues on the ‘dermachat’ forum. Finally, Dr. Pablo Fonda is to be commended for his excellent and inspiring initiative, Teledermasolidaria.

Thanks to Aritz Ardanatz for the translation into English.

Bibliography:

Phelan AL, Katz R, Gostin LO. The novel coronavirus originating in Wuhan, China: challenges for global health governance. JAMA 2020; published online Jan 30. DOI:10.1001/jama.2020.1097.

Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395: 497–506

Fei Zhou et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China, a retrospective cohort study. Lancet 2020; 395: 1054–62

He F, Deng Y, Li W. Coronavirus Disease 2019 (COVID-19): What we know? J Med Virol. 2020 Mar 14

Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 16-24 February 2020

Prof. Tingbo LIANG. Handbook of COVID19, Prevention and Treatment. Zhejiang University School of Medicine

www.worldmeters.info/coronavirus

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