A 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. They are 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 positive test results 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" and “COVID fingers,” with inflammatory nodules resembling chilblains (acral pernio). Unlike adults, children with COVID toes rarely exhibit symptomatic COVID-19 skin findings.¹ Findings from some studies suggest a link to SARS-CoV-2 antibodies (IgA/IgG), whereas 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. These symptoms progress to the stage of hyperemia 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 nonsteroidal anti-inflammatory drugs (NSAIDs) such as 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 such as 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, and vascular causes as well as drug-induced adverse reactions.

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

Meningococcal rash starts as petechiae on the legs, spreading rapidly as 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 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 Antineutrophil cytoplasmic antibody–associated vasculitis causes purpura, nodules, bullae, and livedo reticularis, often on the limbs.¹⁵ Systemic lupus erythematosus 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 phenomenon may cause digital ulcers and gangrene.¹⁸

Vascular causes include medium and small vessel vasculitis. Cutaneous polyarteritis nodosa 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 such as 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 such as toxic epidermal necrolysis (TEN), with systemic effects such as asthma and hepatitis.²³ Sulphonamides are linked to maculopapular rashes, fixed drug eruptions, urticaria, Stevens-Johnson syndrome (SJS), and, less commonly, erythema multiforme.²⁴ Penicillin may cause acute generalized exanthematous pustulosis, often in axillary and inguinal folds, or severe reactions such as SJS, TEN, or drug reaction with eosinophilia and systemic symptoms.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

1. Alharazy S. The dermatologic manifestations of COVID-19: a mini-review. Ann Proteomics Bioinforma. 2021;5(1):042-048. doi:10.29328/journal.apb.1001015
2. Kalra RK, Lewis NL, Shubeck SA, Mychaliska KP. Possible relation of skin and nail changes in an infant to COVID-19 infection. Int J Clin Pediatr. 2022;11(2):39-44.
3. Ioffe OY, Kindzer SL, Kryvopustov MS, et al. Surgical ischemic aspects of COVID-19: management of patients with COVID toes and fingers. Wiad Lek. 2022;75(6):1439-1445. doi:10.36740/WLek202206103
4. Seebacher N, Kirkham J, Smith SD. Cutaneous manifestations of COVID‐19: diagnosis and management. Med J Aust. 2022;217(2):76-78. doi:10.5694/mja2.51621
5. Tsai J, Nagel MA, Gilden D. Skin rash in meningitis and meningoencephalitis. Neurology. 2013;80(19):1808-1811. doi:10.1212/WNL.0b013e3182918cda
6. Group A streptococcal infection. ScienceDirect. Accessed April 30, 2025. https://www.sciencedirect.com/topics/medicine-and-dentistry/group-a-streptococcal-infection
7. Basta MN, Bhatt RA. Purpura fulminans. Medscape. Updated October 24, 2023. Accessed April 30, 2025. https://emedicine.medscape.com/article/2202749-overview?form=fpf
8. Aykent B, Yilmaz O. Skin manifestations in a patient with acute bacterial infective endocarditis. Cleve Clin J Med. 2024;91(11):657-659. doi:10.3949/ccjm.91a.24066
9. Measles (rubeola). Cleveland Clinic. Accessed April 30, 2025. https://my.clevelandclinic.org/health/diseases/8584-measles
10. Magro CM, Dawood MR, Crowson AN. The cutaneous manifestations of human parvovirus B19 infection. Hum Pathol. 2000;31(4):488-497. doi:10.1053/hp.2000.6714
11. Sharma R, Tiwari TN, Goyal S, et al. Imaging characteristics and radiological analysis of rhinoorbital - cerebral mucormycosis. Neurol India. 2025;73(2):286-291. doi:10.4103/ni.ni_950_21
12. van Burik JA, Colven R, Spach DH. Cutaneous aspergillosis. J Clin Microbiol. 1998;36(11):3115-3121. doi:10.1128/JCM.36.11.3115-3121.1998
13. Guarana M, Nucci M. Acute disseminated candidiasis with skin lesions: a systematic review. Clin Microbiol Infect. 2018;24(3):246-250. doi:10.1016/j.cmi.2017.08.016
14. Paparella R, Tarani L, Properzi E, et al. Chilblain-like lesions onset during SARS-CoV-2 infection in a COVID-19-vaccinated adolescent: case report and review of literature. Ital J Pediatr. 2022;48(1):93. doi:10.1186/s13052-022-01296-5
15. Duarte AC, Ribeiro R, Macedo AM, Santos MJ. ANCA-associated vasculitis: overview and practical issues of diagnosis and therapy from a European perspective. Porto Biomed J. 2023;8(6):e237. doi:10.1097/j.pbj.0000000000000237
16. Kole AK, Ghosh A. Cutaneous manifestations of systemic lupus erythematosus in a tertiary referral center. Indian J Dermatol. 2009;54(2):132-136. doi:10.4103/0019-5154.53189
17. Juvenile dermatomyositis (JDM). Cincinnati Children's. Accessed April 19, 2025. https://www.cincinnatichildrens.org/health/j/juvenile-dermatomyositis
18. Trejo O, Ramos-Casals M, García-Carrasco M, et al. Cryoglobulinemia: study of etiologic factors and clinical and immunologic features in 443 patients from a single center. Medicine (Baltimore). 2001;80(4):252-262. doi:10.1097/00005792-200107000-00004
19. Furukawa F. Cutaneous polyarteritis nodosa: an update. Ann Vasc Dis. 2012;5(3):282-288. doi:10.3400/avd.ra.12.00061
20. Gupta A, Singh S. Kawasaki disease for dermatologists. Indian Dermatol Online J. 2016;7(6):461-470. doi:10.4103/2229-5178.193903
21. Hetland LE, Susrud KS, Lindahl KH, Bygum A. Henoch-Schönlein Purpura: A Literature Review. Acta Derm Venereol. 2017;97(10):1160-1166. doi:10.2340/00015555-2733
22. Ravishankar M, Rakshith N. Phenytoin/albendazole induced exanthematous eruptions: a case report. Int J Basic Clin Pharmacol. 2015;4(3):586-589. doi:10.18203/2319-2003.ijbcp20150023
23. Blanca-Lopez N, Soriano V, Garcia-Martin E, Canto G, Blanca M. NSAID-induced reactions: classification, prevalence, impact, and management strategies. J Asthma Allergy. 2019;12:217-233. doi:10.2147/JAA.S164806
24. Chantachaeng W, Chularojanamontri L, Kulthanan K, Jongjarearnprasert K, Dhana N. Cutaneous adverse reactions to sulfonamide antibiotics. Asian Pac J Allergy Immunol. 2011;29(3):284-289.
25. Krishna Kumar D, Rajganesh R, Jaya Shree DB, Cherian SN, Mohamed T. Amoxicillin induced erythematous maculopapular rashes: a case report. Int J Basic Clin Pharmacol. 2020;9(5):806-809. doi:10.18203/2319-2003.ijbcp20201763