Classification of the Cutaneous Manifestations of COVID-19

A Rapid Prospective Nationwide Consensus Study in Spain With 375 Cases

C. Galván Casas; A. Català; G. Carretero Hernández; P. Rodríguez-Jiménez; D. Fernández-Nieto; A. Rodríguez-Villa Lario; I. Navarro Fernández; R. Ruiz-Villaverde; D. Falkenhain-López; M. Llamas Velasco; J. García-Gavín; O. Baniandrés; C. González-Cruz; V. Morillas-Lahuerta; X. Cubiró; I. Figueras Nart; G. Selda-Enriquez; J. Romaní; X. Fustà-Novell; A. Melian-Olivera; M. Roncero Riesco; P. Burgos-Blasco; J. Sola Ortigosa; M. Feito Rodriguez; I. García-Doval


The British Journal of Dermatology. 2020;183(1):71-77. 

In This Article

Materials and Methods

From the start of the study until 8 April 2020 (the last available data), the World Health Organization considered Spain an area of SARS-CoV-2 local transmission.[12] With the support of the Spanish Academy of Dermatology, we asked all Spanish dermatologists (many of them relocated to the acute care of patients during the COVID-19 pandemic) to include patients in this study for 2 weeks. All patients were included who had an eruption of recent onset (previous 2 weeks) and no clear explanation, and suspected (patients presenting with compatible symptoms) or confirmed COVID-19 (with laboratory confirmation of SARS-CoV-2, irrespectively of clinical signs and symptoms), using the definitions of the European Centre for Disease Prevention and Control.[13] A standardized questionnaire was used, and pictures taken for most of the patients. Expecting four or five patterns of similar incidence, we had assumed that collecting 60 confirmed cases would be adequate for an initial description. In the middle of the recruitment period, we had identified 120 cases. Their photographs were independently reviewed by a group of four dermatologists without knowing about the rest of the clinical information, and a consensus was reached on the cutaneous patterns of disease. These patterns were applied to the whole dataset of pictures and were further refined without knowledge of the rest of the clinical information. These morphological diagnostic data were later merged with the rest of the clinical information for analysis.

In most areas, viral tests were especially scarce in this period and were rarely done for less severe cases or cases with a clear diagnosis. Due to the low sensitivity of some diagnostic tests and their scarcity, we accepted cases with clinical diagnosis of the disease (suspected cases) but performed a sensitivity analysis to check that the results did not change when including only confirmed patients. Analysis consisted of description of the data and distribution tests (χ2-test for qualitative variables and ANOVA for quantitative variables) and was done using Stata 16 (StataCorp, College Station, TX, USA).

The study was authorized by an ethics committee (HUGCDN: 2020-172-1-COVID-19) and the Spanish Drug Agency (ACG-CLO-2020-01), and was included in EnCEPP (EUPAS34469). All patients, or their next of kin in the case of minors, gave their informed consent to participate and an explicit consent to use their pictures in publications.