News & Perspective

COVID-19 induced skin manifestations – An emerging complication during the COVID-19 pandemic

Infectious Diseases
4 months ago, OP Editor

COVID-19 induced cutaneous manifestations are emerging as an additional complication during the COVID-19 pandemic. Studies have reported a number of cases of skin manifestations in COVID-19 patients. Italy reported the first incident of rashes observed in COVID-19 patients. The cutaneous eruptions identified in COVID-19 diagnosed patients included typical clinical morphologies such as rash, urticaria, or chickenpox-like lesions.1 Similar cases of patients with cutaneous symptoms at all ages in association with COVID-19 have also been reported worldwide. The heterogeneous skin symptoms included rashes that were mistaken for dengue, achroisquemia in children and critical patients, plaques in the heels, or urticaria.2,3 Given the polymorphic nature of the rashes induced by COVID-19, the severity of the symptoms is highly variable.4 As such, characterization of COVID-19–related rashes and a deeper understanding of the range of implications is critical in determining optimal treatment.

Cutaneous manifestation is a newly reported clinical manifestation of COVID-19 infection. To date, there is no comprehensive characterization and evaluation of the morphological traits related to these skin symptoms, such as the purpuric nature of skin lesions or the mucosal or ophthalmologic features of COVID-19. At present, published cases revealed a heterogenous range of skin manifestations in these COVID-19–infected patients.

The first case of COVID-19 induced skin symptoms was reported in a small cohort (n=18) of patients in Italy. 20.4% of the COVID-19 patients developed cutaneous signs of erythematous rash (n=14), widespread urticaria (n=3) and chickenpox-like vesicles (n=1). Findings indicated no clear correlation between cutaneous manifestation and disease severity. Also, patients either reported a low incidence of itching or absence of itching. Furthermore, the lesions healed within a few days.1

Similar cases of COVID-19 patients reporting of cutaneous manifestations were also reported worldwide. A recent case shared by the Department of Dermatology at Ramon y Cajal University, Madrid, demonstrated focal papillary edema and superficial perivascular lymphocytic infiltrate with red cell extravasation, together with focal parakeratosis and isolated dyskeratotic cells in a biopsy of a 48-year-old COVID-19 patient. Following the onset of fever, primary skin disease such as pruritic, erythematous macules, papules, and petechiae affecting the buttocks, popliteal fossae, anterior thighs, and lower abdomen emerged. Nonetheless, there was no clear evidence linking COVID-19 infection to the skin eruption.4

In another case, an elderly patient admitted in Hôpital Cochin, Paris, for acute respiratory distress also exhibited papulosquamous and erythematous periumbilical patch on the trunk. Subsequently, after the first day of hospital admission, the patient experienced rapid digitate papulosquamous eruption involving the upper arms, shoulder and back.

Attending dermatologist described the symptoms to be clinically identical to pityriasis rosea. However, upon further testing for the presence of COVID-19, no virus was found on the skin. The evidence suggested that based on the increased levels of proinflammatory cytokines, the rash might have been a secondary outcome to the elevated immune response. The rash subsided within a week, but the patient died because of the infection.5

Recently, five clinical patterns have been identified to be related to epidermal disease observed in COVID-19 patients. In the most extensive study to date, Dr. Garcia-Doval, Director of the Research Support Unit of the Spanish Academy of Dermatology and his team, conducted a nationwide consensus study in Spain to define the unexplained morphological patterns associated with COVID-19 skin diseases. The study employed a consensus method on 375 cases of diagnosed COVID-19 patients with unexplained cutaneous manifestations.6

The five types of COVID-19 associated skin lesions were maculopapular eruptions (47%), acral areas of erythema with vesicles or pustules (pseudo-chilblain) (19%), urticarial lesions (19%), livedo or necrosis (6%) and chicken pox-like vesicular eruptions (9%). Incidentally, vesicular eruptions appear early in the course of the disease at 15% more than the other skin manifestations. Besides, the pseudo-chilblain pattern frequently appears late in the evolution of the COVID-19 disease at 59% more frequent than the other symptoms. Importantly, the findings highlighted that the severity of acral lesion increased in response to the severity of COVID-19. Nevertheless, the clinical and epidemiological results were similar for confirmed and suspected cases.6

Findings published by Dr. Garcia-Doval and his team provided a detailed description of the cutaneous disease related to COVID-19 infection that in turn help facilitate the rapid recognition of paucisymptomatic cases by dermatologists. Thus, there is a need for more reported cases and studies of cutaneous manifestations in COVID-19 patients to support improved management of skin lesions.

  1. Recalcati S et al. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020.
  2. Joob B et al. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol Venereol. 2020.
  3. Silva E et al. Cutaneous manifestations in COVID-19: a new contribution. J Eur Acad Dermatol Venereol. 2020
  4. Diaz-Guimaraens et al. Petechial Skin Rash Associated with Severe Acute Respiratory Syndrome Coronavirus 2 Infection. JAMA Dermatol. 2020.
  5. Sanchez A et al. Digitate Papulosquamous Eruption Associated with Severe Acute Respiratory Syndrome Coronavirus 2 Infection. JAMA Dermatol. 2020.
  6. Garcia D et al. Classification of the cutaneous manifestations of COVID‐19: a rapid prospective nationwide consensus study in Spain with 375 cases. British Journal of Dermatology. 2020.

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