key: cord-316654-tihbi0ak
authors: Tosti, G.; Barisani, A.; Queirolo, P.; Pennacchioli, E.; Villa, L.; Lodeserto, A. M.; Vaccari, S.
title: Skin signs resembling vascular acrosyndromes during the COVID‐19 outbreak in Italy
date: 2020-05-25
journal: Clin Exp Dermatol
DOI: 10.1111/ced.14267
sha: 
doc_id: 316654
cord_uid: tihbi0ak

We have read with great interest Dr Estébanez article regarding the case of a 28-year-old woman affected by COVID-19, presenting confluent erythematous-yellowish papules at both heels. After three days, the lesions persisted and became hardened erythematous plaques.

doi: 10.1111/ced.14267

Est ebanez et al. recently published the case of a 28-yearold woman affected by COVID-19, who presented with confluent erythematous, yellowish papules on both heels. After 3 days, the lesions persisted and became hardened erythematous plaques. 1 This presentation was not observed in 18 (20.4%) of 88 patients with COVID-19 hospitalized in Lecco, Italy, who exhibited erythematous rash (n = 14), widespread urticaria (n = 3) and chickenpox-like vesicles (n = 1). 2 However, no clinical images were available. 2 Alramthan and Aldaraji 3 also reported a patient with COVID-19 with cutaneous lesions clinically resembling chilblains, with clinical pictures. The French Society of Dermatology has reported interesting clinical findings in 113 patients during the COVID-19 outbreak: 84/113 patients presented chilblain-like lesions, and 17 of these had a personal history of chilblains or Raynaud syndrome. 4 We have also observed some cutaneous manifestations during the COVID-19 outbreak in Italy during the past 5 weeks, and we report four patients who presented with lesions of the feet.

A 26-year-old white man reported the rapid onset of hardened, erythematous plaques of the heels (Fig. 1a) , with a burning sensation. He was otherwise asymptomatic and was not under any medication.

A 16-year-old white girl, with a personal history of alopecia areata universalis, reported moderate Clinical and Experimental Dermatology pharyngodynia 2 weeks before the onset of erythematous plaques of both heels (Fig. 1b) , which were moderately painful. She was treated with emollients and oral paracetamol. An 18-year-old white girl presented with erythematous plaques on the extensor surface of her toes (Fig. 1c) , while both heels showed erythematous confluent papules (Fig. 1d) . The patient reported itching and pain from the lesions. She was otherwise healthy and asymptomatic. She was treated with emollients and oral paracetamol.

A 48-year-old white man reported a 10-day history of frontal headache, a slight increase in body temperature and marked asthenia. He developed hardened erythematous plaques involving the extensor surface of the toes bilaterally (Fig. 1e) . The clinical presentation was consistent with acrocyanosis. He had already been taking oral paracetamol, and this was continued.

Unfortunately, none of our patients underwent COVID-19 test or skin biopsy. Owing to the level of the pandemic in Italy, COVID-19 tests are not always available and most asymptomatic or oligosymptomatic patients have not yet received a test.

Our cases are suggestive of skin signs related to vascular acrosyndromes. The patients did not have a personal history of chilblains or Raynaud syndrome, and were not taking any medications before the appearance of skin signs, except for the 48-year-old man, who had been taking oral paracetamol. None of them reported wearing tight socks or having any local pressure on the feet. The lesions were similar to those described by Est ebanez et al. 1 Our patients were not tested for COVID-19 and were asymptomatic or only mildly symptomatic at the onset of acral lesions. We believe that the clinical observation of these skin signs, as a possible expression of immune vasculitis, is worthy of being reported to the scientific community at this time. Regarding the situation in Italy, we are not able in many cases to test patients suspected of having COVID-19, and skin signs such as these still do not represent an indication for COVID-19 screening.

We hope to test our four patients for COVID-19 as soon as possible, to understand the aetiology of these clinical conditions in young and mildly symptomatic people.

Cutaneous manifestations in COVID-19: a new contribution

Cutaneous manifestations in COVID-19: a first perspective

Two cases of COVID-19 presenting with a clinical picture resembling chilblains: first report from the Middle East

Soci et e Franc ßaise de Dermatologie. COVID-19 and skin lesions. COVIDSKIN progress report from the SFD