Peer-reviewed article
P167 COVID-19 perniosis, a differential diagnosis to consider in adolescent patients presenting with chilblain-like lesions
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Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This is a medical case series describing five adolescent patients who developed chilblain-like skin lesions (perniosis) possibly associated with COVID-19 infection during 2020-2021. The lesions affected fingers, toes, and heels, with some patients developing ulcers that required treatment. Most lesions resolved within two to six months with various treatments including steroids and calcium channel blockers.
Key points
- Five male adolescents (mean age 16) presented with chilblain-like lesions coinciding with COVID-19 peak infection period
- Three patients had mild respiratory COVID-19 symptoms prior to skin manifestations; one had positive PCR test
- Two patients developed deep, full-thickness heel ulcers; two had superficial ulcerations causing school absence
- Two patients (40%) had spontaneous resolution within 2 months; three (60%) required treatment with aspirin, steroids, nifedipine, or hydroxychloroquine
- No patients had underlying autoimmune connective tissue disorders
Limitations
This is a small retrospective case series of five patients from a single tertiary rheumatology service with limited laboratory confirmation (only one positive PCR test); the causal relationship between SARS-CoV-2 and the skin lesions is not definitively proven in most cases.
Abstract
Abstract Background/Aims Chilblain-like lesions (perniosis) have been reported frequently during COVID-19 pandemic in children and adolescents with no history of exposure to cold temperatures or underlying autoimmune conditions. Patients with these skin changes reported mild COVID-19 symptoms or previous contact with confirmed COVID-19 cases before they became symptomatic. In the majority of cases, a causal relationship between SARS-CoV-2 infection and chilblain-like lesion has not been proven. Methods Retrospective review of patients with chilblain-like lesions, possibly secondary to SARS-CoV-2 infection, presenting to a tertiary Adolescent Rheumatology service between January and August 2021. Results We identified five, male, adolescent patients (mean age, 16 years old) who presented with new onset of chilblain-like lesions affecting fingers, toes and heels in December 2020, which coincided with the peak of second wave of COVID-19 infection. One month prior to skin changes occurrence, 3 out of 5 patients experienced mild respiratory COVID-19-like symptoms and the rest of the patients were asymptomatic but were in contact with COVID-19 positive cases following outbreaks in schools. 1 of 3 symptomatic patients had a positive COVID-19 PCR test prior to skin manifestations. 2 out of 4 patients with heel lesions had deep, full thickness skin loss heel ulcers and 2 of 5 patients had superficially ulcerated lesions on a finger and toes, respectively, resulting in inability to attend school. None of the patients had any other symptoms or signs to suggest an underlying autoimmune connective tissue disorder. Demographics, clinical features and serological data are summarised in Table 1. One patient underwent a biopsy of heel ulcer which was histologically consistent with perniosis. In two patients (40%) chilblain like lesions resolved spontaneously within 2 months. Three patients (60%), with progressive ulcerated lesions, required various combinations of treatments with aspirin, calcium channel blockers (nifedipine), topical or oral steroids and hydroxychloroquine with complete resolution of symptoms within 6 months. Conclusion Chilblain-like lesions, including heel involvement associated with mildly symptomatic COVID-19 infection, have been reported before. Our mini-case series raises awareness of ulcerating chilblain like lesions possibly secondary to COVID-19 in adolescent patients, which require early recognition and instigation of treatment leading to better patient’s outcomes. P167 Table 1 Demographics, clinical, laboratory findings of patientsCaseAgeLesion locationCOVID-19 symptomsSARS-CoV-2 PCR / SARS-CoV-2 AbAutoimmune profile/ complement levelsTreatment/ skin symptoms resolution (months)116Fingers, toes, heelsNoNA/ NegativeANA positive (1:80) ENA negative anti-dsDNA normal, C3, C4 normalAspirin, prednisolone, nifedipine, hydroxychloroquine /6216fingers heels, toesNoNA/ NegativeANA negativePrednisolone, nifedipine/6318Toes, heelsrespiratoryPositive/NAANA negativeNil/1416Fingers, toesrespiratoryNegative/ NegativeANA positive (1:320) ENA negative anti- dsDNA normal C3, C4 normalNil/2516Fingers, toes, heelsrespiratoryNA/ NegativeANA negativenifedipine/6 NA: not available, PCR: polymerase chain reaction, SARS-CoV-2: severe acute respiratory syndrome coronavirus 2 Disclosure N. Gak: None. V. Choida: None. M. Leandro: None. D. Sen: None. C. Ciurtin: None. C. Fisher: None.