Br J Dermatol. To describe clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19. The Academy has gathered evidence from dermatologists regarding skin manifestations of COVID-19. Pernio (Chilblains), SARS-CoV-2, and COVID Toes Unified Through Cutaneous and Systemic Mechanisms. Histologic features also mimic those of idiopathic urticaria and thus limit the value of skin biopsy. Piccolo V., Neri I., Filippeschi C. Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients. Conflicts of interest: Drs Freeman, Lipoff, Rosenbach, Kovarik, Takeshita, Hruza, and Fox are part of the American Academy of Dermatology (AAD) Covid-19 Ad Hoc Task Force. Additionally, they advocated further studies to determine the dynamic viral load and viremia at different points in the rash (prior, during, and after). Most chilblains observed during the COVID-19 outbreak occur in patients who are negative for COVID-19 on polymerase chain reaction and serology testing. There were 318 patients (63%) identified with pernio-like changes in the setting of confirmed or suspected COVID-19 (TableI There may be confirmation bias in reporting of cases. 4 [e-pub ahead of print]. 2020 Sep/Oct;24(5):504-517. doi: 10.1177/1203475420937978. , Neither patient was critically ill. If nearly a million cases of a disease occurs you are bound to have either misdiagnoses of other viruses, coincident drug rashes, or other random findings. 2022 Oct 19;2(10):e0000488. 2020;34:e291e293. A summary of this evidence is available below and can be downloaded as a PDF. More than 40 million people have been infected with the severe acute respiratory syndrome coronavirus 2 since the first infection was reported in December 2019 from Wuhan, China. Fiehn C. Familial chilblain lupus-what can we learn from type I interferonopathies? National Library of Medicine The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. All Rights Reserved. While the debate continues, if these lesions are truly a COVID-19 manifestation, they are, fortunately, associated with high survival rates (96.4% to 98.7%) and few or no systemic symptoms. Lesions in this series resolved in a median of 2weeks. The urticarial, morbilliform, exanthematous eruptions described seem thus far both nonspecific and inconsistent enough to aid in either making a diagnosis or offering prognostic interpretations, but as with the rest, warrant monitoring. One of these skin manifestations may be pernio-like lesions of the feet and/or hands. This information will be critical to understanding the significance of these cutaneous lesions and empowering physicians and other health care providers to counsel patients appropriately. In patients with other COVID-19 symptoms, pernio-like lesions typically appeared after other symptoms. 2020. Explore the Academy's new and improved Learning Center, with enhanced ease of use for the education you trust. Also important is our ability to reassure the public regarding the relatively benign clinical course observed in most of our patients. Clin Dermatol. Perniolike lesions on the fingers of right hand after the second dose of PfizerBioNTech vaccine. The other patient was a 47-year-old woman who noticed LR of her right leg after being outside for about 30 minutes. Pernio-like lesions lasted a median of 14days (interquartile range, 10-21days). Increasing evidence suggests pernio-like lesions are cutaneous manifestations of coronavirus infectious disease 2019 (COVID-19). Given the association between the new onset of perniolike manifestations and COVID19 infection, Yang X., Yu Y., Xu J. Federal government websites often end in .gov or .mil. Epub 2020 Oct 1. April 22, 2020 Fabbrocini G, Vastarella M, Nappa P, Annunziata MC, Camela E, Greco V, Gaudiello F, Alessio M, Pierri L, Catzola A, Guarino A. Image at top shows vaso-occlusive lesions in COVID-19. COVID-19 is a devastating disease with multiorgan manifestations. Learn to map out your practices future, build skills with popular hands-on courses, and tackle day-to-day challenges of practice management. Like those with morbilliform rash or urticaria, patients with COVID-19 with vesicular eruptions have high survival rates (96.1% to 96.6%). Epub 2021 Jan 21. However, some reports describe prominent keratinocyte acantholysis contributing to formation of intraepidermal vesicles, which is a relatively unusual histologic finding. We documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions. [e-pub ahead of print]. Conclusions: Many morphologies were nonspecific, whereas others may provide insight into potential immune or inflammatory pathways in COVID-19 pathophysiology. International registry data indicate that morbilliform eruptions are the most common cutaneous manifestation in patients with laboratory-confirmed COVID-19. These cases represent novel cases of new-onset pernio in patients without prior history, temporally associated with high levels of undetected community-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) circulation during the COVID-19 pandemic. Disclaimers: This commentary was written on April 17, 2020 for a publication date of April 22, 2020. Our objectives were to assess location, timing, and duration of the pernio-like lesions, and to analyze patients' comorbidities, COVID-19 severity, and disease outcomes. IRB approval status: The registry was reviewed by the Partners Healthcare (Massachusetts General Hospital) Institutional Review Board and was determined to not meet the definition of Human Subjects Research. The issues related to the COVID-19 pandemic are changing by the millisecond. While trends are beginning to become apparent, the fact is that we are in the data-gathering phase of this epidemic, and dermatologists should not reach foregone conclusions based on scattered case reports in the medical literature or lay press. COVID toes: Pernio-like lesions Clin Dermatol. [Epub ahead of print], Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for Dengue. Six other pathology reports from patients without laboratory confirmation showed findings consistent with pernio-like changes: (1) 1 with mild spongiosis, vacuolar interface change, few apoptotic epidermal keratinocytes, and perivascular and perieccrine lymphoid infiltrate, (2) 3 reporting superficial and deep perivascular, perieccrine lymphocytic or lymphohistiocytic infiltrate, without evidence of vasculitis, (3) 1 reporting a subepidermal blister with small vessel lymphocytic vasculitis without microthrombi, and (4) 1 reporting lymphocytic vasculitis with rare microthrombi and overlying epidermal necrosis. Rabaan AA, Mutair AA, Aljeldah M, Shammari BRA, Sulaiman T, Alshukairi AN, Alfaresi M, Al-Jishi JM, Al Bati NA, Al-Mozaini MA, Bshabshe AA, Almatouq JA, Abuzaid AA, Alfaraj AH, Al-Adsani W, Alabdullah M, Alwarthan S, Alsalman F, Alwashmi ASS, Alhumaid S. Genes (Basel). 2023 Mar 31;7:101-112. doi: 10.5414/ALX02373E. The rash lasted 20 minutes. The content included in this commentary may no longer be factual or relevant by the publication date. Br J Dermatol. Circulating neutrophil numbers are consistently higher in survivors of COVID-19 than in non-survivors, and the infection also induces lymphocytopenia that mostly affects the CD4+ T cell subset, including effector, memory, and regulatory T cells. Herpes simplex virus (HSV) and varicella-zoster virus (VZV) reactivations have been reported in conjunction with COVID-19 infection. Tang N., Li D., Wang X., Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Unit of Dermatology, Case presentation. No abstract available. Manalo et al presented two cases of unilateral transient livedo reticularis (LR) in COVID-19 patients. Interestingly, in a systematic review of 895 patients with COVID-19, 105 (12%) had urticarial lesions, and in 17 (16%) of these 105 the urticaria began before the onset of the other COVID-19 symptoms, suggesting that it can be a clue to diagnosis in appropriate clinical settings and can help guide early testing. , Additionally, a systematic review found that pre-existing rheumatologic conditions were more common in patients with presumed COVID-19-related pernio-like lesions, raising the possibility that underlying diagnoses contributed to development of the acral lesions. We cannot exclude an epiphenomenon. The reader is encouraged to stay abreast of developments via the CDC and local government and institutional health care authorities. In many locations, testing has been limited to sicker patients, selecting against testing of patients with mild disease, including those who may develop COVID-19associated pernio-like skin lesions. Snotwatch COVID-toes: An ecological study of chilblains and COVID-19 diagnoses in Victoria, Australia. As experience with caring for patients with COVID-19 has accumulated since the onset of the pandemic, so has our understanding of its associated cutaneous manifestations and their clinical implications. Explore hundreds of Dermatology World Insights and Inquiries articles by clinical area, specific condition, or medical journal source. Fernandez-Nieto D., Jimenez-Cauhe J., Suarez-Valle A. Published by Elsevier Inc. All rights reserved. 7 Given evolving understanding of COVID-19, clear public health messaging regarding these pernio-like lesions is paramount. , Increasing evidence suggests pernio-like lesions are cutaneous manifestations of coronavirus infectious disease 2019 (COVID-19). Certainly, some patients may have new-onset pernio from other nonCOVID-19 causes. 8600 Rockville Pike An official website of the United States government. Galvan Casas C., Catala A., Carretero Hernandez G. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. In addition, 20 patients had close contact with patients with confirmed COVID-19 (eg, child of health care worker who tested positive); though in 1 case, the patient subsequently tested PCR negative for COVID-19. 5 Pernio, or chilblains, is a superficial inflammatory vascular response that occurs on acral skin, usually after cold exposure, typically in children and young to middle-aged women.6 In this large international registry-based case series, we evaluate clinical characteristics of patients with suspected or confirmed COVID-19 who presented with pernio-like lesions on acral surfaces. We are also unable to estimate the incidence or prevalence of this condition. We cannot exclude an epiphenomenon. Certain rashes, welts and blisters are associated with COVID-19 infection. Please enable it to take advantage of the complete set of features! official website and that any information you provide is encrypted A large international registrybased case series of 318 patients with perniolike lesions and confirmed or suspected COVID19 infection showed that skin manifestations were only on the feet in 84% of patients and only on the hands in 5.1% of patients.6 Please enable it to take advantage of the complete set of features! However, proponents of the association with COVID-19 point to outbreaks of chilblain-like lesions corresponding to COVID-19 waves and propose that an efficient, type I interferon-driven antiviral response could induce pernio-like lesions and suppress both symptoms and confirmatory testing. Accessibility FOIA eCollection 2023. The pernio-like lesions in most patients developed either concurrently with, or after, COVID-19 symptoms, although 174 patients with confirmed or suspected COVID-19 presented only with pernio-like skin lesions. New Engl J Med 2020 Apr 8. doi: 10.1056/NEJMc2007575. (11) This may represent an important skin sign of systemic disease heralding intravascular, multiorgan clotting and may suggest alternate, supplemental therapeutic options, as the authors speculate. This case, together with those already reported in the literature, raises the question of whether the vaccineelicited immune response could be involved in the development of perniolike manifestations, as it has been described following COVID19 infection. Bethesda, MD 20894, Web Policies COVID-19: risk for cytokine targeting in chronic inflammatory diseases? Whether early recognition of these lesions can prompt treatment decisions that decrease systemic thrombotic events or increase overall survival requires further research. Epub 2020 Aug 3. Cutaneous manifestations were an erythematous rash (14 patients), widespread urticaria (3 patients), and chickenpox-like vesicles (1 patient). The patient in this manuscript has given written informed consent to the publication of her case details. We would like to thank the American Academy of Dermatology Ad Hoc Task Force on COVID-19 and staff at the American Academy of Dermatology for their logistical and administrative support. Clinicians trace a ferocious rampage through the body, from brain to toes, and emerging reports have demonstrated that COVID-19 can impact almost every organ and system in the body, including the skin and perhaps particularly, the toes. , Some patients in the registry with negative antibodies had clinical histories predictive of high pretest probability; for example, a physician caring for COVID-19 patients in Milan and a child with a PCR-positive parent. Viral isolation (utilizing PCR) by nasopharyngeal and oropharyngeal swabs confirms the diagnosis. COVID-19 and cutaneous manifestations: A review of the published literature. [Epub ahead of print], Su CJ, Lee CH. Science. The site is secure. 2020;S1931-5244(20)30070-0. doi:10.1016/j.trsl.2020.04.007. Federal government websites often end in .gov or .mil. Check out DermWorld Insights & Inquiries for the latest updates from Dr. Warren Heymann. Pernio-like skin changes of the feet and hands, without another explanation, may suggest COVID-19 infection and should prompt confirmatory testing. Lesions tend to resolve after about eight days without scarring. Limitations: Confirmation bias is possible. Initially described as varicella-like, vesicular eruptions in COVID-19 have been described in both localized and diffuse distributions. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Some of the more commonly reported dermatological manifestations associated with COVID-19 disease include erythematous rashes, maculopapular and urticarial eruptions, and chilblain-like (also called pernio-like) lesions.2 This case report illustrates an atypical presentation of a cutaneous lesion associated with COVID-19 and reviews the potential pathophysiology and clinical . 2020. 16. A case series cannot estimate population-level incidence or prevalence. Br J Dermatol. Transl Res. Further, if pernio is indeed a later disease course phenomenon in at least a subset of patients, then it may be prudent to repeat antibody testing and/or seek delayed IgG testing for suspected patients. Epub 2021 Feb 2. A cross-sectional study of nearly 900 patients with COVID-19 found a significantly higher prevalence of HSV-1 and VZV than in the hospital population, even when adjustments were made for numerous comorbidities. Zhang Y., Xiao M., Zhang S. Coagulopathy and antiphospholipid antibodies in patients with Covid-19. On the other end of the spectrum, "COVID toes," or acral, pernio-like lesions, seem to be more common in young patients, children and adolescents in particular, and portend a mild course, or develop after asymptomatic infection. Whitman J.D., Hiatt J., Mowery C.T. He died of his illness 3.5 weeks after admission. -, Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. and transmitted securely. Given the inordinate, undeserved attention cast on hydroxychloroquine thus far, it pains me to raise this point, but as hydroxychloroquine is often employed as a therapeutic agent in treating pernio, one could speculate that if patients with COVID-19 are treated with hydroxychloroquine, even if they would have developed pernio post-infection, the anti-malarial therapy may suppress or abort the development of those characteristic lesions. An official website of the United States government. This site needs JavaScript to work properly. The 2 IgM-positive and IgG-negative antibody-confirmed patients both tested negative by PCR. Disclaimer. To describe clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19. For example, a study of more than 330,000 community-based patients in the United Kingdom found that patient-reported skin rash was associated with positive COVID-19 testing and was more predictive than fever. The registry queried patient demographics, dermatologic symptoms, COVID-19 history and symptoms, and past medical history. With three million cases, if there were a striking, consistent rash, it would likely be well described by this point. The clinical differential diagnosis included urticaria, urticarial vasculitis, idiopathic plantar hidradenitis, and neutrophilic dermatosis. Int J Dermatol. An international dermatology registry was circulated to health care providers worldwide through the American Academy of Dermatology, International League of Dermatologic Societies, and other organizations. -, Fernandez-Nieto D., Jimenez-Cauhe J., Suarez-Valle A. Vol. The site is secure. Among individuals with pernio-like lesions, SARS-CoV-2 PCR positivity rates ranged from 3 to 7 percent during the wild-type wave of the pandemic but decreased during the subsequent waves of SARS-CoV-2 variants. 9500 Euclid Avenue , Cleveland , Ohio 44195 | 800.223.2273 | TTY 216.444.0261, What Long COVID Means for Rheumatologists (Video), Cutaneous Manifestations of COVID-19 in Special Populations, Effects of COVID-19 on Blood Sugar and Type 2 Diabetes, Optimal Management of High Risk Immunocompromised Patients in the COVID-19 Era, Morbilliform rash (containing macules and papules, resembling measles), Pseudo-chilblains (also known as COVID toes, painful inflammation of the digits in response to cold), Vaso-occlusive lesions (due to thrombosis and occlusion of small arteries, with subsequent ischemia). All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. Piccolo V, Neri I, Manunza F, Mazzatenta C, Bassi A. Int J Dermatol. In fact, in the reported case no skin biopsy was performed and the diagnosis was clinical. Zhang Y., Qin L., Zhao Y. Interferon-induced transmembrane protein-3 genetic variant rs12252-C is associated with disease severity in COVID-19. The https:// ensures that you are connecting to the For 55% of patients, pernio-like lesions were their only symptom. chilblains, COVID-19, dermatology, pernio, public health, COVID-19, coronavirus infectious disease 2019; Ig, immunoglobulin; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. [Epub ahead of print], Estbanez A, Prez-Santiago L, Silva E. Guillen-Climent S, et al. Two days later she was febrile with chest pain, testing positive for COVID-19. Unauthorized use of these marks is strictly prohibited. We must be cognizant of confirmation bias not every case of pernio need be associated with COVID-19 (the corollary being the apocryphal Freudian quote sometimes a cigar is just a cigar). The weather in North America has been cooler this spring in parts of Canada and small regions of North America (though March overall was another record-warm month), due partially to an abnormal jet stream as a result of climate change. The fact that many of our patients were otherwise asymptomatic and had not been tested for COVID-19 likely reflects limited availability of COVID-19 PCR testing at the start of the United States outbreak and variable state-by-state and country-by-country testing regulations. For example, in the article What are Covid toes? [e-pub ahead of print]. Other cutaneous findings that have been reported with COVID-19 include oral lesions; reactivation of viral infections; rash resembling symmetrical drug-related intertriginous and flexural exanthema; small-vessel vasculitis; cutaneous hyperesthesia; papulosquamous eruptions; and erythema nodosumlike lesions. The rapid and complete transformation of our world health and economy is spellbinding, disorienting, heart wrenching, and devastating. 8600 Rockville Pike The vast majority of AI models used in medicine today are "narrow specialists," trained to perform one or two tasks, such as scanning mammograms for signs of breast cancer or detecting lung disease on chest X . Unable to load your collection due to an error, Unable to load your delegates due to an error. and transmitted securely. Rome -, Mateus J, Grifoni A, Tarke A, et al. COVID-19-associated cutaneous abnormalities are often grouped into five major categories: Morbilliform eruptions are common in many viral illnesses and were reported in patients with COVID-19 early in the pandemic. HHS Vulnerability Disclosure, Help Update your Find a Dermatologist profile, the Academy's directory that's visited by over 1 million people a year. 9 Before Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. Given current testing criteria, many patients lacked COVID-19 testing access. The https:// ensures that you are connecting to the Before For this subanalysis, we included patients with new-onset pernio-like skin changes in the setting of confirmed or suspected COVID-19 and excluded patients with prior history of pernio. Perhaps such coagulopathies could be contributing to LR or other acral pernio-like lesions. Explanations for these patients include (1) findings were not COVID-19-related, (2) false-negative test results, or (3) testing occurred after viral clearance, with pernio-like lesions representing a late clinical finding. Learn how to reduce burdens with health tech. A brilliant colleague and friend wrote on March 30, 2020, Theres no COVID rash. In patients with other COVID-19 symptoms, pernio-like lesions typically appeared after other symptoms. New Engl J Med 2020 Feb 28 doi: 10.1056/NEJMoa2002032 [Epub ahead of print]. [Epub ahead of print], Schett G. Sticherling M, Neurath MF. When symptoms were present, the pernio-like lesions occurred before (13%), at the same time (15%), or after (54%) the COVID-19 symptoms. As viral information goes viral, so do potential misconceptions. Epub 2020 Aug 9. Methods: Would you like email updates of new search results? The site is secure. A new dermoscopic pattern for chilblain-COVID-19-like skin lesions in adolescents. It is important for the dermatologist to recognize such clinical findings in order to provide a proper diagnosis and therapeutic management. Part I of this series was referenced; Parts II and III were personal reflections; Part IV is referenced. Lesions were mostly truncal. Limitations: These lesions are most commonly seen in hospitalized patients with moderate to severe COVID-19 and are associated with higher risks of severe pneumonia and intensive care unit admission and relatively low survival rates (78.9% to 81.8%). 10 Access resources to help you promote the specialty in your community and beyond. Importantly, although young patients with COVID-19 have presented with stroke, we are not aware of any cases of concomitant pernio-like lesions and strokes.19. Science magazine titled a recent piece How does coronavirus kill? Genetic Variants and Protective Immunity against SARS-CoV-2. San Gallicano Dermatological Institute IRCCS, Elsevier Public Health Emergency Collection, Presence in a health care facility where COVID-19 infections have been managed. Chilblain-like lesions during the COVID-19 pandemic: should we really worry? SARS-CoV-2 and allergy - what have we learned after two and a half years? Limitations of this case series include incomplete testing for COVID-19, especially in otherwise asymptomatic patients. As a library, NLM provides access to scientific literature. Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. That may be true for some of these patients, but given the large number of new reports of pernio coincidentally with the COVID-19 pandemic, it is unlikely to explain all cases. Explore the Academy's new and improved Learning Center, with enhanced ease of use for the education you trust. J Am Acad Dermatol 2020; Mar 22 pii: S0190-9622(20)30454-0. doi: 10.1016/j.jaad.2020.03.036. [Epub ahead of print], Jimenez-Cauhe J, Ortega-Quijano D, Prieto-Barrios M, Moreno-Arrones OM, Fernandez-Nieto D. Reply to COVID-19 can present with a rash and be mistaken for Dengue: Petechial rash in a patient with COVID-19 infection. 8 Accessibility aDepartment of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, bMedical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, cDepartment of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, dDepartment of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany, eDepartment of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina, fDepartment of Dermatology, St. Louis University, St Louis, Missouri, gDepartment of Dermatology, University of California, San Francisco, California. Additionally, a systematic review found that pre-existing rheumatologic conditions were more common in patients with presumed COVID-19-related pernio-like lesions, raising the possibility that underlying diagnoses contributed to development of the acral lesions. This duration is likely an underestimate, because the clinical courses of many patients are ongoing, and the data were only available for patients with completed disease courses. 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. 2020. We do not endorse non-Cleveland Clinic products or services Policy. Pernio-like lesions on the ( A-F ) toes and ( G ) fingers, MeSH 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. (3) In a reply to Recalcati, Henry et al reported the case of a 27-year-old woman who presented with odynophagia, diffuse arthralgia, and pruritic disseminated erythematous plaques with facial and acral involvement, diagnosed as urticaria on dermatological consultation. Clinicians trace a ferocious rampage through the body, from brain to toes. Additionally, an analysis of 296 hospitalized patients with COVID-19 in the United States found that mucocutaneous findings were associated with the need for mechanical ventilation, even when adjusted for age, body mass index and comorbidities. To evaluate and summarize the clinical, laboratory, and histopathological characteristics of pernio-like lesions reported in the literature. Although multiple possibilities exist, reports from Europe of pernio-like lesions during the COVID-19 surge suggest a true association,1 sharing sensitive information, make sure youre on a federal 5, A large international registrybased case series of 318 patients with perniolike lesions and confirmed or suspected COVID19 infection showed that skin manifestations were only on the feet in 84% of patients and only on the hands in 5.1% of patients. Additionally, a systematic review reported a possible link between vesicular eruptions and neurologic symptoms, including headache, dysgeusia, irritability and confusion. HHS Vulnerability Disclosure, Help Abbasi J. Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Desai SR, Harp J, Takeshita J, French LE, Lim HW, Thiers BH, Hruza GJ, Fox LP. 2020;83(1):e61e63. We would like to thank Drs Philippe Dieude, Cynthia Yalowitz, Rachel Hub, Emily Arch, Ambrose Su, and Haydee Knott for providing photographs, Drs Rina Allawh, Graeme Lipper, Lynda Kauls, Lee Albert, Shannon Keiser, and Sarah Smilow for providing pathology, Dr Mariko Yasuda for her input on pathophysiologic mechanisms, and Dr Marlys Fassett for her contributions regarding antibody testing. The other 2 of 6 patients with suspected COVID-19 with histopathology reported vascular changes, including lymphocytic vasculitis, which can sometimes be seen in conjunction with variants of pernio.
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