Comment on “Characterization of acute acro-ischemic lesions in non-hospitalized patients: A case series of 132 patients during the COVID-19 outbreak”
Authors: Diego Fernandez-Nieto, Juan Jimenez-Cauhe, Ana Suarez-Valle, Oscar M. Moreno-Arrones, David Saceda-Corralo, Arantxa Arana-Raja, Daniel Ortega-Quijano
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We thank Dr. Ruggiero and colleagues1Ruggiero G. Arcangeli F. Lotti T. et al.Reply to: "Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak".J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar for their interest in our article. We read their study of erythema perniolike lesions in the Italian pediatric population during the coronavirus disease 2019 (COVID-19) outbreak. They described findings regarding the distribution and duration of skin lesions that were similar to those of our Spanish cohort, and also described a low rate for systemic symptoms or positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test results. They also reported the use of a wide variety of treatments in 74 of 100 cases (74%), including topical steroids, antibiotics, and heparin. There were no consistent differences between the improvement rates at day 12, although physicians' choice for treatment may have been biased by the severity of the disease. We are struggling with uncertainty in these challenging times. On one hand, there are severely ill COVID-19 patients who may present with ischemic acral lesions that may progress to gangrene2Zhang Y. Cao W. Xiao M. et al.Zhonghua Xue Ye Xue Za Zhi. 2020; 41: E006PubMed Google Scholar because of COVID-19–induced coagulopathy and thrombotic microangiopathy. On the other hand, there are asymptomatic young patients with subtle ecchymotic and vesicular acral lesions, which have been associated with viral hypersensitivity reactions, microthrombi, overexpression of interferon 1, and immune vasculitis.3Kolivras A. Dehavay F. Delplace D. et al.Coronavirus (COVID-19) infection-induced chilblains: a case report with histopathologic findings.JAAD Case Rep. 2020; 6: 489-492Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar,4Suchonwanit P. Leerunyakul K. Kositkuljorn C. Cutaneous manifestations in COVID-19: lessons learned from current evidence.J Am Acad Dermatol. 2020; 83: e57-e60Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar The latter are not usually associated with COVID-19 pneumonia or thromboembolic events. However, overlapping features may coexist. In fact, both groups of patients may represent the mild and severe ends of the spectrum of COVID-associated coagulopathy.5Zhang Y. Xiao M. Zhang S. et al.Coagulopathy and antiphospholipid antibodies in patients with COVID-19.N Engl J Med. 2020; 382: e38Crossref PubMed Scopus (1602) Google Scholar We must take into account that a causal relation between acral skin lesions and SARS-CoV-2 has not been fully established yet. These lesions have been increasingly reported in several countries coincident with the COVID-19 pandemic spread. However, most studies report a low positive test-result rate for SARS-CoV-2 polymerase chain reaction, with little access to diagnostic tests. We believe that these skin manifestations are delayed COVID-19 manifestations; hence, the negative results. Serologic studies will be needed to elucidate this point. What should we do with these patients? Because the epidemic curve is slowly declining worldwide, confinement measures are being relaxed. These skin manifestations could be of great value in identifying primary cases, permitting the health care system to implement control and prevention measures and thus avoiding the spread of the virus. Until we have more information about the risk of SARS-CoV-2 transmission in these patients, we should recommend maintenance of isolation measures, especially if diagnostic tests are unavailable. Reply to: "Characterization of acute acro-ischemic lesions in non-hospitalized patients: A case series of 132 patients during the COVID-19 outbreak"Journal of the American Academy of DermatologyVol. 83Issue 3PreviewTo the Editor: We read with interest the article by Fernandez-Nieto et al.1 Cutaneous manifestations of coronavirus disease 2019 (COVID-19) are rarely reported. In their letter, Fernandez-Nieto et al1 described an increased number of acroischemic lesions in young patients from Spain. Most patients were asymptomatic or mildly symptomatic, and none of them developed COVID-19 pneumonia or any other complication. Full-Text PDF