During the COVID-19 pandemic, there has been an emergence of a chilblains-like phenomenon affecting fingers and toes. This is poorly understood and not always associated with positive coronavirus virology (antibodies or blood/respiratory PCR). Often children have had no typical symptoms of COVID-19 infection. It tends to affect younger people, can occur a few weeks after COVID-19 infection, or late in the disease course. Children and young people may present with swollen toes and/or fingers, which may be erythematous, purpuric or violaceous, associated with cutaneous manifestations such as macules, papules, desquamation and ulceration. The lesions may be pruritic or painful.
The majority of children and young people presenting in this way have a benign course and the lesions resolve without intervention within one month. Therefore, not all patients will require a referral and if the patient presents very early, or is already improving, can have expectant management.
The differential diagnosis of dactylitis includes infection (cellulitis, osteomyelitis), sickle-cell anaemia, gout, sarcoidosis and spondyloarthropathy e.g. psoriatic arthritis. The presentation with cutaneous lesions may, in a small number of children and young people, represent an underlying systemic connective tissue disease or vasculitic process such as systemic lupus erythematous or cryoglobulinaemia.
In all children and young people presenting with erythematous and/or swollen digits, a full history and systematic examination, including joint assessment, should be carried out.
If the patient is systemically unwell, consider referral to hospital under the acute paediatric medical team/rheumatology for further investigation and management.
In the absence of an obvious alternative diagnosis such as cellulitis or injury, the following investigations should be performed, if possible (and included in the referral letter):
If there are other systemic features such as fever, malaise, joint symptoms or signs (arthralgia, swelling, erythema, heat, restricted movement, widespread rash) – discuss with paediatric rheumatology.
If the child or young person is otherwise systemically well, give advice to keep the hands and feet warm and covered and avoid cold/damp exposure. Symptomatic management such as simple analgesia and anti-histamines for pruritis should be provided. In the majority of cases with mild symptoms, reassurance is all that is required.
If needed, consider a short course of topical steroids, such as:
If topical steroids have already been trialled without success, consider a short course of oral prednisolone, 1mg/kg once daily for 7 days.
In the absence of any other concerning features, give worsening advice and advise the patient/carer to seek further review if ongoing symptoms at 6 weeks. At this stage, a referral to paediatric rheumatology is warranted.
RHC for Health Professionals