A few days ago, the possibility that COVID-19 was also producing skin lesions, in the form of chilblains, especially in children, appeared in the media. Dr. Curell, pediatrician, explains what they are and when to worry about these skin alterations.
What exactly are chilblains and when do they appear?
The appearance of chilblains (“perniosis”) or perniosis consists of a clinical picture, generally triggered by cold, in which inflammatory lesions appear, of bilateral and symmetrical distribution, especially on the dorsal and lateral face of the fingers, but also sometimes on the toes, nose or pinnae or other locations. They may cause a sensation of pain, stinging or itching, and usually heal spontaneously, with complications such as ulceration or superinfection being rare.
The factors and diseases that predispose to the development of perniosis or chilblains or similar lesions (perniosis-like) are environmental factors (humidity and cold, professions in which cold and wet food is handled or wearing wellington boots, for example); diseases associated with low body weight, such as celiac disease, anorexia nervosa or malnutrition; some neoplasms; autoimmune diseases (lupus erythematosus and others); crack consumption and, finally, some rare genetic diseases.
Do they affect only, or mostly, children? Why?
It is not known why it occurs in some people and not in others, when exposed to the same environmental conditions. It affects more females than males and there may be some familial predisposition.
When there were no heating systems in most homes, it mainly affected children and adolescents in autumn and winter, especially those with lower body mass. Therefore, and currently, it affects more socially disadvantaged populations or people with underlying pathologies.
These days it has been commented that there could be a relationship between COVID-19 and chilblains in children, being one more symptom of the disease. Could this be so?
Various dermatological manifestations have been described in cases of COVID-19 and in relatives of patients infected with SARS-Cov19, especially in children and adolescents. These lesions may be similar to chilblains (perniosis-like) and/or vasculitis in extremities, such as acroischemia (or rashes with pale or purplish coloration of the skin due to lack of circulation), and this could suggest that the virus acts directly by altering blood clotting in a disseminated manner (in the form of disseminated intravascular coagulation – DIC) or by causing inflammation in the smaller peripheral blood vessels in the distal parts of the extremities (autopsies of deceased COVID-19 patients in Italy have detected virus in blood vessels).
But other dermatological lesions have also been described: urticaria (indistinguishable from those appearing in allergic reactions), vesicles (similar to chickenpox or hand-foot-mouth disease), morbilliform rashes (like measles) and/or petechiae (hemorrhagic type lesions, like small hematomas) which are also associated with numerous viral or bacterial infections already known previously. It is not known if it can also affect the nails, as do some enteroviruses, such as Coksackie or similar (onychomadesis), all more related to the immune response against the virus itself.
SARS-CoV infection is so recent that, day by day, new publications are appearing that provide knowledge about its clinical presentations, diagnosis, prevention and treatment.
In any case, the best prevention is to follow the instructions of the health authorities: respect confinement and the distance of 1.5 meters between people, scrupulous hand washing and contacting the pediatrician, as well as photographing any lesions that may appear in children and adolescents.
What is known about the above statement and the possibility that these patients could be carriers of the disease?
Fortunately, COVID-19 appears to affect most children and adolescents mildly. Many have no symptoms (and may be carriers and transmit the virus to their contacts) or have mild symptoms, indistinguishable from other catarrhal processes. Cutaneous symptoms may be part or the only symptoms of the disease in the younger population. As with other infections, these skin manifestations may be caused more by the immune response of the host than by the direct action of the virus on the skin.
How should parents who detect chilblains in their children act and how can they be cured?
Diagnosis is clinical, by observation of the lesions described. In the absence of treatment, the lesions heal spontaneously and without sequelae in most cases. Environmental protection measures against the cold, such as appropriate clothing and heating or thermal insulation systems in the home, can prevent or reduce episodes. Some drugs such as topical corticosteroids and some oral or local medications in the most severe cases may be useful, such as calcium antagonists, minoxidil or others.