Skin Findings In COVID-19

Although patient samples reported have been small, as dermatologists and clinicians it is important to be aware of the skin findings that may appear in patients with COVID-19, so we can be aware, look for and know how to manage these findings. So far, clinical documentation of skin manifestations from patients in China has been scarce although being where the virus originated.

Queries and reports of skin manifestations in COVID-19 have increased. Most of the patients experiencing these symptoms have been younger — children with a median age of 13 and young adults in their early 30s. Most documented cases are reports of particular skin manifestations including a letter to the editor from March 26, 2020, published by Dr. Recalcati in the Journal of European Academy of Dermatology and Venereology¹ and a case series of dermatologic findings in Spain.²

COVID-19 Skin Manifestations

Rashes that have been described in COVID-19 patients include livedo reticularis, vasculitis, hives, chicken pox-like vesicles or blisters, hand dermatitis, and an erythematous lacy rash with petechiae similar to that of dengue fever. “COVID toes” result from infarcts in the digits that lead to an appearance of crusty black plaques on the fingertips and distal toes, and resemble the appearance of a frostbite, chillblains or perniosis. Skin conditions do not increase the risk of acquiring coronavirus, in spite of the skin manifestations present.

Acral lesions that have been observed in patients with COVID-19 are typically erythematous and bumpy, papules resembling chillblains.² As described in the report, over a week’s time, the lesions gradually became flatter and more purpuric in color. The predominant locations were the distal toes or the heels, and occasionally, the lesions were bilateral. They resolved without necessitating additional care. The patients affected did not exhibit symptoms of ischemia or Raynaud’s phenomenon — denying any symptoms affected by extreme weather or changes in temperature. Occasionally the patients reported discomfort upon palpation or rubbing though for the most part the lesions appear to be asymptomatic. Most patients were in general good health and did not present with severe COVID-19 symptoms; however, they reported mild fevers, cough, congestion in the preceding weeks and some had been in contact with infected individuals. Not all patients had a clearly positive test. The test was positive in some patients, while negative in others, which could have been a false negative, a late manifestation in which the PCR had already reversed to negative or no coronavirus infection at all. In some patients with an initial negative test, further studies such as an x-ray showed other confirmatory findings such as bilateral pneumonia.

A report from Italy, specifically the Alessandro Manzoni Hospital located in the town of Lecco, described dermatologic manifestations in patients with coronavirus.¹ Specifically, the authors analyzed skin manifestations in 148 patients directly or indirectly, with data included from 88 of those patients. About 20% of patients developed skin manifestations, 8 at initial onset and 10 during the course of hospitalization. Dermatologic manifestations included urticaria, erythematous rashes and pox-like vesicles in 3, 14, and 1 patient, respectively. Most of the skin manifestations were located on the trunk. There was little to no itching and the lesions resolved in a matter of days without intervention. There was no association between the skin and the severity of disease.

In Spain’s Ramon y Cajal Hospital in Madrid, another group of dermatologists reported similar manifestations in the skin including urticaria, chicken pox-like blisters and an erythematous lacy rash.³ They cited difficulty obtaining photographs due to staff shortages and fear of infection when in close proximity to the subject. Occasionally, biopsies were performed and demonstrated the typical findings in an urticarial skin biopsy: dermal edema, scattered lymphocytes and eosinophils. Patients reported symptomatic relief with antihistamines. They have also found nonspecific cases of a maculopapular rash similar to that seen in other viral exanthems.

Retrospectively, it appears as though the authors find similarities in the skin manifestations with COVID-19 to be very similar to viral exanthems that can be observed in common viral infections. Overall, there is a desire to obtain more information from patients and their caregivers to better understand how the skin responds and reacts to COVID-19 infection.

The American Academy of Dermatology has established a registry for physicians and dermatologists to document any skin findings that may be possibly linked to the coronavirus, COVID-19.⁴ While the general symptoms of COVID-19 consists of fever, cough, headache, anosmia, dyspnea, rhinorrhea, ageusia, asthenia, myalgia and diarrhea, few skin manifestations have been described. Most of this information can be reported with a simple survey if you have an encounter a patient with COVID-19 who has developed skin manifestations, or on the other hand, for dermatology patients who have then developed COVID-19.

While many impressions are hypothetical and require further investigation, the appearance of lesions similar to that which has been described suggest that we should explore the possibility that these patients may have been in contact with COVID-19 and inquire about upper respiratory symptoms, fevers and other suggestive symptoms in the weeks prior to their appearance. Simultaneously, the appearance of these lesions could help facilitate a diagnosis linked to COVID-19 in patients who otherwise exhibit no symptoms. It would also be of interest to perform further confirmatory studies in these patients such as a reverse PCR test and an IgM-IgG antibody serological test to evaluate exposure.

References:

1. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020 [published online ahead of print.]

2. Landa N, Mendieta-eckert M, Fonda-pascual P, Aguirre T. Chilblain-like lesions on feet and hands during the COVID-19 Pandemic. Int J Dermatol. 2020 [published online ahead of print].

3. Fernandez-Nieto D, Ortega-Quijano D, Segurado-Miravalles G, Pindado-Ortega C, Prieto-Barrios M, Jimenez-Cauhe J. Comment on: Cutaneous manifestations in COVID-19: a first perspective. Safety concerns of clinical images and skin biopsies. J Eur Acad Dermatol Venereol. 2020 [published online ahead of print].

4. COVID-19 Dermatology Registry. American Academy of Dermatology. Available at: https://www.aad.org/member/practice/coronavirus/registry. Accessed May 20, 2020.