COVID-19 Skin Manifestations Identified in Spain

By Marilynn Larkin

May 13, 2020

NEW YORK (Reuters Health) - Spanish dermatologists have documented five major patterns of COVID-19 effects on the skin that are associated with different patient demographics and prognosis.

"Our research provides a general classification of skin manifestations of COVID-19 that can be very useful for any clinician seeing patients with COVID-19," Dr. Ignacio Garcia-Doval of the Spanish Academy of Dermatology in Madrid told Reuters Health by email. "Using the supplementary atlas, any doctor can become reasonably proficient in the diagnosis of COVID-19-associated skin findings in a short time."

"I also think that this is the starting point for further research, such as research into the diagnostic value of these signs, their value as epidemiological markers, description of less common cutaneous signs and their evolution, histopathology, mechanism of disease, and maybe therapy," he said.

Dr. Garcia-Doval and colleagues analyzed a nationwide case collection of images and clinical data. By consensus, they described five clinical patterns, and then described the association of these patterns with patient demographics, timing in relation to symptoms of COVID-19, severity, and prognosis.

As reported in the British Journal of Dermatology, COVID-19 skin manifestations may be classified as:

- acral areas of erythema with vesicles or pustules (pseudo-chilblain; 19%); associated with younger patients and lasting for a mean of 12.7 days.

- other vesicular eruptions (9%); associated with middle-aged patients, lasting for a mean of 10.4 days.

- urticarial lesions (19%); resembling wheals that are usually itchy and mostly distributed on the trunk or across the body.

- maculopapular eruptions (47%); lasting for a mean of 8.6 days and associated with more severe disease.

- livedo or necrosis (6%); associated with older patients with more severe disease (10% mortality).

Vesicular eruptions appear early in the course of the disease (15% before other symptoms). The pseudo-chilblain pattern frequently appears late in the evolution of COVID-19 (59% after other symptoms), and the rest tend to appear with other symptoms.

COVID-19 severity shows a gradient from less severe disease in acral lesions to most severe in the other lesions. Clinical and epidemiological findings were similar for both confirmed and suspected cases. For the most specific patterns (pseudo-chilblain and vesicular), alternative diagnoses seemed unlikely.

Dr. Garcia-Doval said, "We are not yet sure of the diagnostic value of these findings. Some are likely to be induced by the virus, such as vesicular lesions and probably pseudo-chilblain, but others might not be induced by SARS-CoV-2. Furthermore, those that appear late in the eruption, such as pseudo-chilblain, might be associated with negative tests."

"Overall, only 6% of the patients in our sample had cutaneous lesions preceding the systemic symptoms of COVID-19 that could have acted as a warning sign," he noted.

Dr. John Ingram, Editor-In-Chief: of the British Journal of Dermatology, commented in an email to Reuters Health, "This study is the most definitive piece of research on the skin features associated with COVID-19 to date. There has been speculation for some time that the virus is responsible for a number of skin signs, but until now these had largely been individual or small-scale case reports. This study represents a much more systematic and thorough categorization of the features."

Dr. Adam Friedman, Interim Chair of Dermatology and Director of Translational Research at George Washington School of Medicine and Health Science in Washington, DC, commented by email, "The interesting emerging findings are the vasculopathic eruptions, which include what has been called COVID toes or 'toevids.' These are perniosis-like eruptions on the feet (red-purple swollen papules and plaques on the toes)."

"Perniosis typically is an abnormal response to cold temperatures," he said. "However, it is unclear if temperature has anything to do with the COVID-related findings... What is also very interesting is the timing of this eruption, as it tends to occur well after the onset of symptoms."

"At GW, we are finding that these patients are often molecular-test negative, meaning the test is not picking up viral RNA or COVID-19-specific genes," he said. "This could suggest that this occurs in individuals who effectively clear the infection. We are following up with antibody testing to confirm this theory."

"The other vascular, more purpuric eruptions fit with this pattern, but represent likely a more robust immune response resulting in blood vessel destruction," he continued. "As of now, the US Centers for Disease Control and Prevention is not considering these findings to be specific to infection, as opposed to loss of smell/taste, for example."

"That said," he added, "there is an emerging trend suggesting that toevids are a good prognostic feature, indicating viral clearance without the induction of a cytokine storm that is the primary source of patient morbidity and mortality. More data are needed to confirm this, but that is my take-away thus far."

SOURCE: British Journal of Dermatology, online April 29, 2020.