19-year-old female with painful, purpuric nodules in the phalanges of her fingers

A 19-year-old female presented with painful purpuric nodules localized to the distal phalanges of her fingers. It is associated with intermittent swelling, itching, and pain. Three weeks earlier, she had experienced mild upper respiratory symptoms, including nasal congestion and sore throat, which resolved without medical intervention. Shortly thereafter, she learned that a close friend had tested positive for COVID-19 prior to her illness.

On examination, the lesions were erythematous and violaceous, tender to touch, and consistent with chilblain-like lesions. She denied systemic symptoms such as fever or fatigue, and was otherwise healthy.

What is the diagnosis?

Immunologic testing for SARS-CoV-2 returned positive results, supporting the diagnosis of chilblain-like lesions, commonly referred to as COVID-19 fingers.

Epidemiology and Etiology

Initially, COVID-19 was associated with minimal skin symptoms, but later, diverse dermatologic manifestations were documented, including urticarial, maculopapular, papulovesicular, purpuric eruptions, livedo reticularis, and thrombotic ischemic lesions. A notable presentation is "COVID toes" with inflammatory nodules resembling chilblains (acral pernio), typically affecting toes and fingers. Unlike adults, children with COVID toes rarely exhibit symptomatic COVID-19 skin findings.¹ Some studies suggest a link to SARS-CoV-2 antibodies (IgA/IgG), while others attribute these lesions to cold exposure in barefoot children. Chilblain-like lesions during the pandemic may indicate a robust immune response, suggesting innate immunity and a favorable prognosis. Their seasonal increase in spring and temporal association with the pandemic imply a connection to COVID-19 infection.²

Course

Early symptoms (3–5 days after infection) include itching, burning, or tingling in the fingers without noticeable skin changes. This progresses to the stage of hyperaemia with redness or purplish discoloration, swelling, and warmth. Painful lesions, blisters, or ulcers may develop during the ischemic phase. Recovery typically occurs within 10 to 14 days, though some cases may last for several months. Most patients with COVID fingers experience mild symptoms, and the lesions typically resolve without leaving scars. However, severe cases involving ischemia that can lead to gangrene are rare and usually occur in individuals with higher risk factors, such as diabetes.³

Management 

Symptomatic relief for the patient involved using topical corticosteroids to reduce inflammation, oral antihistamines to manage itching or discomfort, and pain relief with NSAIDs like acetaminophen or indomethacin. Additionally, moisturizing creams were applied to address dryness and itching. If cold exposure was suspected, gentle rewarming of the affected areas was also recommended. These interventions aimed to alleviate discomfort and support the healing process, ensuring the patient's comfort during recovery.⁴

In cases where symptoms are severe, advanced therapies may include the use of vasodilators like nifedipine or cilostazol to enhance blood flow to the affected areas. Additionally, if a secondary bacterial infection develops, antibiotics may be prescribed to treat the infection effectively. These interventions aim to manage complications and support recovery.⁴

Discussion

When discussing this case, it is important to consider a broad range of potential etiologies, including infectious, autoimmune, vascular causes, as well as drug-induced adverse reactions.

Infectious etiology may include that of bacterial, viral, or fungal origins.

Meningococcal rash starts as petechiae on the legs, spreading rapidly to purpura, necrosis, and possible limb gangrene.⁵ Streptococcal sepsis can cause cellulitis or necrotizing fasciitis, often on the limbs, or a scarlet fever-like rash on the trunk.⁶ Purpura fulminans presents with symmetric hemorrhagic necrosis and bullae on the limbs.⁷ Infective endocarditis shows petechiae, splinter hemorrhages (nails), Osler’s nodes (fingers/toes), and Janeway lesions (palms/soles).⁸ 

In children, measles typically begins with fever, cough, and Koplik spots inside the mouth, followed by a red maculopapular rash that starts on the face and spreads downward to the body and limbs.⁹ Parvovirus B19 infection causes a bright red “slapped cheek” rash on the face, which is then followed by a lacy, blotchy rash on the trunk and limbs.¹⁰ 

Mucormycosis begins in the lining of the nose and sinuses and quickly spreads to affect the face, eye area, and brain. The infection is marked by blood vessel invasion, blood clots, and extensive tissue death.¹¹ Cutaneous aspergillosis starts with skin changes such as spots, bumps, or raised patches. In newborns, it may appear as pustules or sores that produce pus.¹² Invasive candidiasis, can lead to skin rashes that are either widespread or appear as small lumps and bumps.¹³ 

Autoimmune diseases can cause varied skin lesions. Chilblains and palpable purpura present as painful, red, itchy lesions on fingers and toes.¹⁴ ANCA-associated vasculitis causes purpura, nodules, bullae, and livedo reticularis, often on the limbs.¹⁵ SLE presents with malar and maculopapular rashes, often on the face and sun-exposed areas.¹⁶ Juvenile dermatomyositis shows reddish-violet rashes on knuckles, elbows, and knees.¹⁷ Cryoglobulinemia can lead to acral cyanosis and necrosis.20 Raynaud’s may cause digital ulcers and gangrene.¹⁸

Vascular causes include medium and small vessel vasculitis. Cutaneous PAN presents with nodules, livedo reticularis, ulcers, gangrene, and sometimes purpura or edema, mainly on the legs.¹⁹ Kawasaki disease features systemic signs with mucocutaneous lesions like strawberry tongue, cracked lips, swollen hands/feet, and perineal desquamation.²⁰ Henoch-Schönlein Purpura starts with flat or urticarial lesions progressing to palpable purpura and petechiae, primarily on the buttocks, lower legs, arms, and trunk.²¹

Several drugs can cause adverse skin reactions. Phenytoin may lead to a symmetrical exanthematous rash with red spots, often on the trunk.²² NSAIDs can cause hives, angioedema, pustular eruptions, and severe reactions like TEN, with systemic effects such as asthma and hepatitis.²³ Sulphonamides are linked to maculopapular rashes, fixed drug eruptions, urticaria, SJS, and, less commonly, erythema multiforme.²⁴ Penicillin may cause AGEP, often in axillary and inguinal folds, or severe reactions like SJS, TEN, or DRESS.²⁵

The distinguishing features for each differential are outlined in the table.

Conclusion

She was treated with oral ibuprofen for symptomatic relief and was advised to avoid further cold exposure. No additional pharmacological interventions were necessary.

Lesions were completely resolved after 4 weeks.

References

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