August 2020

Pernio-like Skin Lesions in COVID-19

Figure 1. Pernio-like lesions on the (A-F) toes and (G) fingers in (A, C, D, E) COVID-19 polymerase chain reaction-positive patients, (E, F) antibody-positive patients, and (B, G) close contacts of COVID-19 polymerase chain reaction-positive patients. Reprinted with permission from the American Academy of Dermatology. Reprinted with permission. All rights reserved.

As the COVID-19 pandemic continues to rage, so-called “COVID toes” continue to be reported around the world. These dermatologic manifestations were catalogued in a recent international registry-based case series, adding to the emerging evidence that pernio-like lesions may be a cutaneous manifestation of COVID-19.

The series, published by an international group of researchers in the Journal of the American Academy of Dermatology, describes clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19. The group documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions (age range, 16 – 57 y). Patients with pernio-like lesions were generally young and had benign clinical courses. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19.

Significantly, pernio-like lesions were the only symptom for 55% of patients. In patients with other COVID-19 symptoms, pernio-like lesions typically appeared after other symptoms and lasted a median of 14 days (interquartile range, 10-21 days).

The researchers concluded that pernio-like lesions, without another explanation, may suggest COVID-19 infection. They advised that such patients may still be infectious and pose a public health risk, because skin lesions developed in at least 4 patients in this report before COVID-19 PCR confirmation, and the lesions developed in 14 while still PCR positive. They also proposed that pernio-like lesions be added to the testing criteria for COVID-19 and prompt confirmatory testing.

Source: Freeman EE, McMahon DE, Lipoff JB, et al. Pernio-like skin lesions associated with COVID-19: A case series of 318 patients from 8 countries. J Am Acad Dermatol. 2020;83:486-92.


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