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.