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Benign but potentially painful skin conditions may persist for months in some patients with COVID-19, preliminary data from an international registry suggested.

About 5% of patients with pernio, or chilblains, had "long-hauler" toe symptoms lasting 60 days or longer. In two cases, the toe symptoms lasted 4 to 5 months. Some patients also had symptoms commonly associated with COVID-19, such as persistent dry cough or fever, but others had dermatology-dominant symptoms, particularly those patients whose skin symptoms persisted beyond the usual symptomatic phase.

Certain other dermatologic manifestations of COVID-19 lasted for a month or longer in at least one case, reported Esther Freeman, MD, PhD, of Massachusetts General Hospital in Boston, during the European Academy of Dermatology and Venereology (EADV) Virtual Congress.

"There are a subset of patients with skin manifestations of COVID that have long-hauler or long COVID symptoms," said Freeman. "This is particularly notable for pernio or chilblains, and we believe that this phenomenon is actually underreported in the registry, maybe even more common that we see in this data."

In response to a question, Freeman said limited correlative data have been collected to date to make any definitive statements about the association of long-haul dermatologic symptoms and other COVID-19 symptoms. Persistent pain and discomfort associated with pernio also appears to be uncommon.

"I think we need to be reassuring to most of our patients who develop pernio or chilblains in the setting of COVID-19," she added. "Both in the registry and in my own personal cohort of patients, symptoms resolved after a median duration of 15 days. I do think that's an underrepresentation, as we've seen lots of our patients lasting 4 and 6 weeks. But for most of our patients, the pain and discomfort only lasts about a week."

Discoloration of toes linked to pernio has not been associated with necrosis or other underlying tissue damage, Freeman told 麻豆传媒 via email. Although pernio/chilblains is more commonly associated with cold, the condition is distinct from frostbite, which can result in gangrene, she noted.

The findings came from the international COVID-19 Dermatology Registry, hosted by the American Academy of Dermatology. Established in early April with the support of the International League of Dermatologic Societies, the registry has accumulated data on more than 1,000 patients from 41 countries. About 30% of the cases collected to date have laboratory confirmation of COVID-19. Freeman and colleagues findings for the first 716 patients enrolled in the registry.

The EADV presentation focused on 224 patients (90 with laboratory confirmation of COVID-19) whose clinicians provided information on the duration of dermatologic symptoms. The cohort included 98 patients with pernio, 29 with morbilliform rash, 28 with urticaria, 25 with macular erythema, 20 with vesicular eruptions, 20 with papulosquamous eruptions, and three with retiform purpura.

Median duration for all symptoms was 12 days, and 7 days for the subset with laboratory-confirmed disease. The median duration periods ranged from 5 days for urticaria to 20 for papulosquamous eruptions and retiform purpura.

The pernio subgroup had the most outliers or long haulers, as five of the 98 had toe symptoms that persisted for 60 days or more compared with one each in the subgroups with vesicular and papulosquamous eruptions. The patients with morbilliform rash had a median duration of 7 days, and two of 29 patients had symptoms that lasted about 30 days. Urticaria lasted 5 days, and in one patient the symptom persisted for 30 days. In general, laboratory confirmation was associated with shorter symptom duration, except for papulosquamous eruptions, which had a 20-day median duration.

Freeman described the clinical course of a pernio long hauler whose toe symptoms were ongoing at 133 days. The patient initially complained of fatigue and cough, and the onset of pernio with erythema and pain was reported on day 7. Laboratory results confirmed COVID-19 on day 24 after prior negative tests, and the pernio had worsened. On day 41, the patient tested positive again and had ongoing fatigue. At last follow-up, the patient's fatigue had improved, but the pernio persisted.

Beginning in the summer, published reports documented patients with months-long duration of COVID-19 symptoms, including fatigue, neurologic symptoms, and cardiac symptoms, said Freeman. Whether the same was true of cutaneous manifestations of the illness was unclear, and the registry data have provided evidence that some patients do have long-haul dermatologic symptoms.

"Nine months after the onset of the COVID-19 pandemic, there is increasing appreciation for persistent morbidity beyond the acute phase of the disease," Freeman said in conclusion. "Urticarial and morbilliform eruptions were relatively short in duration, while pernio/chilblains and papulosquamous eruptions were longer-lasting."

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