Cutaneous Manifestations in Patients With COVID-19

A Preliminary Review of an Emerging Issue

A.V. Marzano; N. Cassano; G. Genovese; C. Moltrasio; G.A. Vena

Disclosures

The British Journal of Dermatology. 2020;183(3):431-442. 

In This Article

Abstract and Introduction

Abstract

Background: The infection caused by the recently identified SARS-CoV-2, called coronavirus disease-19 (COVID-19), has rapidly spread throughout the world. With the exponential increase of patients worldwide, the clinical spectrum of COVID-19 is being better defined and new symptoms are emerging. Numerous reports are documenting the occurrence of different cutaneous manifestations in patients with COVID-19.

Objectives: To provide a brief overview of cutaneous lesions associated with COVID-19.

Methods: A literature search was performed in the PubMed, Scopus and Web of Science databases up to 30 April 2020. This narrative review summarizes the available data regarding the clinical and histological features of COVID-19-associated skin manifestations.

Results: The literature reports showed a great heterogeneity in COVID-19-associated cutaneous manifestations, as well as in their latency periods and associated extracutaneous symptoms. Pathogenic mechanisms are unknown, although the roles of a hyperactive immune response, complement activation and microvascular injury have been hypothesized. Based on our experience and the literature data, we subdivided the reported cutaneous lesions into six main clinical patterns: (i) urticarial rash; (ii) confluent erythematous–maculopapular–morbilliform rash; (iii) papulovesicular exanthem; (iv) chilblain-like acral pattern; (v) livedo reticularis–livedo racemosa-like pattern; and (vi) purpuric 'vasculitic' pattern. These six patterns can be merged into two main groups: the first – inflammatory and exanthematous – includes the first three groups listed above, and the second includes the vasculopathic and vasculitic lesions of the last three groups.

Conclusions: The possible presence of cutaneous findings leading to suspect COVID-19 puts dermatologists in a relevant position. Further studies are needed to delineate the diagnostic and prognostic values of such cutaneous manifestations.

Introduction

A novel zoonotic enveloped RNA virus of the family Coronaviridae, which has been named 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2), was identified in hospitalized patients with pneumonia in Wuhan, China, in December 2019. The infection caused by the virus, called coronavirus disease-19 (COVID-19), has rapidly spread throughout the world, becoming pandemic in early March 2020.[1]

The clinical spectrum of COVID-19 is rather heterogeneous, ranging from unapparent or mild symptoms to critical fatal forms with respiratory failure, septic shock or multiorgan dysfunction. The clinical features at onset of illness vary, but, over the disease course, patients present mainly with fever and respiratory symptoms. However, various signs and symptoms can occur, and among the most common are fever, cough, fatigue, anorexia, shortness of breath, sputum production, myalgia, dyspnoea, rhinorrhoea, ageusia, anosmia, pharyngodynia, headache and chills.[1] With the exponential increase of infected patients worldwide, the clinical characteristics of COVID-19 are being better defined and new symptoms are emerging.

In most of the early reports from China, cutaneous lesions were not generally included in the COVID-19 clinical spectrum, apart from a few exceptions. For instance, Guan et al. described skin rash in 0·2% of 1099 hospitalized patients, without specifying clinical patterns or further details.[2] Hoehl et al. observed a faint rash and minimal pharyngitis in one traveller returning from Wuhan to Germany in February 2020 who tested positive for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (RT-PCR) of her throat swab.[3] Subsequently, a case of COVID-19 presenting with purpuric lesions mimicking dengue has been reported.[4] In Iran, the clinical findings of COVID-19 found in a 15-day-old neonate were fever, lethargy, respiratory distress without cough and cutaneous mottling.[5]

Another report, which analysed a series of 88 patients with COVID-19 to describe the rate and type of skin lesions, drew the attention of the scientific community to COVID-19-associated cutaneous manifestations.[6] In all of these patients, history of intake of any new drug in the previous 15 days was excluded. Cutaneous manifestations developed in 18 patients (20%) either at the onset of the disease (n = 8) or after admission (n = 10), and consisted of erythematous rash (n = 14), widespread urticaria (n = 3) and chickenpox-like vesicles (n = 1). The trunk was the most frequently affected area, and itch was mild or absent. Skin lesions usually disappeared in a few days and did not show any apparent correlation with COVID-19 severity.

Subsequently, various reports of skin manifestations in patients with COVID-19 have been published. It should be kept in mind that, at the beginning of this vast outbreak, the rapidly increasing rate of infected patients and the parallel multitude of severe and critical patients could have hampered systematic skin assessments. Therefore, cutaneous lesions are likely to have been underestimated for obvious reasons, including the paucity of dermatology consultations in this group of patients.[7] Moreover, cutaneous lesions may have been neglected as their duration can be very short and local symptoms can be minimal or absent. The difficulty in determining the actual prevalence of COVID-19-associated skin manifestations has also been linked to the fact that in some countries only patients with respiratory illness or requiring hospitalization are screened.[8]

The aim of our article is to provide a brief overview of the cutaneous manifestations associated with COVID-19, accepting the preliminary nature of such data.

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