Comment on 'Two cases of COVID-19 presenting with a clinical picture resembling chilblains: first report from the Middle East': pernio unrelated to COVID-19.

Linked Article: Alramthan and Aldaraji

We read with interest the recent paper by Alramthan and Aldaraji in Clinical and Experimental Dermatology, contributing to the spectrum of COVID‐19 clinical manifestations. Since the COVID‐19 outbreak began, a number of new symptoms have been described. Some of these were not initially highlighted but could be a distinguishing feature of COVID‐19 infection, such as anosmia or ageusia. Therefore, it is believed that a newly reported symptom, termed acute acro‐ischaemia, is another novel clinical manifestation of COVID‐19 infection.

Alramthan and Aldaraji described two previously healthy women presenting with red–purple papules on the dorsal aspect of the fingers bilaterally. One of the patents also had diffused subungual erythema in the right thumb. Both patients presented to a clinic in Kuwait, but as they had recently travelled from the UK, a reverse transcription‐PCR test for SARS‐CoV‐2 infection was performed, which gave a positive result.

The authors suggested that such skin lesions might be a new clinical manifestation of COVID‐19 infection in otherwise asymptomatic individuals.

We report two patients with similar clinical manifestation, but a different diagnosis.

Two patients presented with similar lesions on the fingers also suspected to be induced by COVID‐19. Patient 1 was a 16‐year‐old girl, who presented with a 1‐week history of violaceous erythema over the distal joints (Fig. 1). Patient 2 was a 16‐year‐old boy, who presented with a 3‐week history of acral erythema (Fig. 2a,b) and red papules with an orange hue (Fig. 2c).

Figure 1

Patient 1. Erythematous–violaceous papules over the distal joints.

Figure 2

Patient 2. (a) Erythematous macules on the hands with slight oedema and discrete blanching; (b) erythematous macules on the fingers with blanching, which had been present before medical evaluation; (c) reddish papules on the finger.

Laboratory investigations including complete blood count; erythrocyte sedimentation rate; routine urine tests; serum biochemical tests; assays for antinuclear antibodies; serum complement components C3 and C4, anticardiolipin antibodies, antiphospholipid and beta‐2‐gycoprotein‐I, cryoglobulins and cold agglutinins; serological tests for enterovirus, Epstein–Barr virus, herpesvirus 6, parvovirus B19, mycoplasma, rubella and measles; levels of IgG, IgM and IgA; and PCR (nasopharyngeal swab) for SARS‐CoV‐2 were performed, all of which gave normal or negative results. Skin biopsy was not taken. In consequence, a clinical diagnosis of pernio (chilblains) was made. After 1 week of follow‐up, the cutaneous lesions had notably improved.

Thus, we hypothesize that the increasing number of clinical cutaneous manifestations being reported are not caused directly by COVID‐19, but are related to the globally imposed strict stay‐at‐home rules. In our opinion, this acral manifestation should be better classified as simple pernio. The lockdown was declared in Spain on March 14, and since then, children have not been allowed to go outdoors. It is possible this immobility has directed children to not move as frequently as normal, and cold temperatures could also have contributed to the appearance of this outbreak of pernio. The two patients reported by Alramthan and Aldaraji had recently been on a trip to the UK, a colder country than Kuwait, and cold is associated with pernio. Thence, the concurrent positivity for COVID‐19 may be a coincidence, as the virus is widely spread and young people tend to have no or mild symptoms.