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Coronavirus (COVID-19) infection–induced chilblains: A case report with histopathologic findings

Until now, the skin findings reported in association with coronavirus disease 2019 (COVID-19) infection remain sparse, nonspecific, and devoid of any prognostic significance.1,2 This Case Report emphasizes a novel cutaneous sign of utmost importance for dermatologists to recognize

Fig : Coronavirus disease 2019–induced chilblains. Violaceous infiltrated plaques that appeared abruptly on an erythematous background, with features typical of chilblains.

Case report

A 23-year-old man presented with a 3-day history of acute-onset, violaceous, infiltrated, and painful plaques on the toes and lateral aspect of the feet. The appearance of the plaques was preceded by 3 days of a low-grade fever (37.7°C) and a dry cough. His clinical history was notable for psoriasis, which had been treated with secukinumab for 30 months; however, the secukinumab had been stopped 1 month before to minimize immunosuppression during the COVID-19 pandemic. No additional treatment had been initiated. The patient had many violaceous, infiltrated, and painful plaques on an erythematous background on the dorsal aspect of the toes and the lateral sides of the feet (Fig 1). The hands and fingers were unaffected. The patient did not have a history of Raynaud phenomenon, acrocyanosis, chilblains (perniosis), or photosensitivity. A complete skin examination result was otherwise unremarkable, and dermoscopy showed normal proximal nail folds. A complete blood cell count; erythrocyte sedimentation rate; coagulation study results (prothrombin time, activated partial thromboplastin time, and thrombin time); a D-dimer test result; renal, hepatic, and thyroid function test results; an antinuclear antibody test; and an Epstein-Barr serology result were either within normal limits or negative. Urine was devoid of protein or blood. Finally, a PCR test result for SARS-CoV2 (COVID-19), performed on a nasopharyngeal swab, was positive.

Fig 2

Coronavirus disease 2019–induced chilblains. A, Histopathologic findings simulating chilblain lupus with an absence of significant papillary dermal edema. There is a superficial and deep lymphoplasmacytic infiltrate. B, Vacuolar interface dermatitis with singly necrotic (apoptotic) keratinocytes and smudging of the basement membrane zone. Some of the necrotic keratinocytes are in the superficial layers of the epidermis. (Hematoxylin-eosin stain.)


COVID-19 infection–induced chilblains have been observed during the pandemic and communicated among the French and Belgian dermatologic networks. To our knowledge, it had not been previously reported because of the limited availability of PCR testing for COVID-19. Young patients presenting with chilblains have lacked criteria sufficient to allow for a COVID-19 PCR test. Because of the recent outbreak of chilblains, concurrent with the increase of COVID-19 cases, COVID-19 has been widely suspected as the etiology. We have further suspected an association because chilblains have been appearing during the warmer springtime rather than the usual cold winter period. Similar to this case, other young patients presenting with chilblains have also lacked a history of chilblains, Raynaud phenomenon, or collagen vascular diseases such as lupus erythematosus. These cases have all been in children and young adults whose feet have been more affected than their hands. Chilblains may be the inaugural symptom of COVID-19, and a fever and dry cough may be minimal or even absent. These patients appear to have an indolent course, often not knowing that they have a COVID-19 infection and that they are likely contagious. Acute acral cyanosis in the absence of chilblains has also been observed (unpublished data).

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