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

Abstract

To the Editor: We read with great interest the recent paper by Fernandez-Nieto et al1Fernandez-Nieto D, Jimenez-Cauhe J, Suarez-Valle A, et al. Characterization of acute acroischemic lesions in nonhospitalized patients: a case series of 132 patients during the COVID-19 outbreak. J Am Acad Dermatol. 83(1):e61-e63.Google Scholar 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.2Piccolo V. Neri I. Filippeschi C. et al.Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients [e-pub ahead of print].https://doi.org/10.1111/jdv.16526Date: 2020Date accessed: May 6, 2020Google Scholar In their article, Fernandez-Nieto et al1Fernandez-Nieto D, Jimenez-Cauhe J, Suarez-Valle A, et al. Characterization of acute acroischemic lesions in nonhospitalized patients: a case series of 132 patients during the COVID-19 outbreak. J Am Acad Dermatol. 83(1):e61-e63.Google Scholar 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.3Zhang Y. Cao W. Xiao M. et al.Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia [in Chinese].Zhonghua Xue Ye Xue Za Zhi. 2020; 41: 302-307PubMed Google Scholar 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.4Kolivras A. Dehavay F. Delplace D. et al.Coronavirus (COVID-19) infection-induced chilblains: a case report with histopathological findings.JAAD Case Rep. 2020; 6: 489-492Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar 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. Characterization of acute acral skin lesions in nonhospitalized patients: A case series of 132 patients during the COVID-19 outbreakJournal of the American Academy of DermatologyVol. 83Issue 1PreviewTo the Editor: The coronavirus disease 2019 (COVID-19) has been associated with several skin manifestations, including widespread urticaria, erythematous rash, and varicella-like exanthem.1,2 Ischemic and ecchymotic acral lesions have also been described in patients with severe forms of COVID-19 as a manifestation of clotting disorders.3 Coincident with the COVID-19 pandemic, similar acral lesions have being described in healthy young patients.4 However, the clinical implication and relation to COVID-19 remains unclear. Full-Text PDF Comment on: “Acral findings during the COVID-19 outbreak: Chilblain-like lesions should be preferred to acroischemic lesions”Journal of the American Academy of DermatologyVol. 83Issue 3PreviewTo the Editor: We appreciate the interest in our article and the comment by Drs Piccolo and Bassi1 in which they propose to use the term “chilblain-like lesions” instead of “acroischemic lesions” to denominate the acral lesions in patients with coronavirus disease 2019 (COVID-19). At the time we were analyzing our study, only 2 papers reporting “acroischemia” in COVID-19 patients had been published, and thus, we acquired the same name. In the next days, numerous articles were published reporting these acral lesions with different terms, including chilblain-like lesions, chilblains, pseudochilblain, erythema pernio-like, perniosis-like, vascular skin symptoms, vascular acrosyndromes, COVID-19–induced chilblains, or chilblains of lockdown, among others. Full-Text PDF