Cutaneous Manifestations of SARS-CoV-2 Infection

Thy Huynh; Xavier Sanchez-Flores; Judy Yau; Jennifer T. Huang

Disclosures

Am J Clin Dermatol. 2022;23(3):277-286. 

In This Article

Abstract and Introduction

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the coronavirus disease 2019 (COVID-19) pandemic, affecting people worldwide. SARS-CoV-2 infection is a multisystem disease with potential for detrimental effects on various systemic organs. It affects people of all ages with varying degrees of disease severity. Patients with SARS-CoV-2 infection commonly present with dry cough, fever, and fatigue. A clinical spectrum of skin findings secondary to SARS-CoV-2 has also been reported. The most common cutaneous patterns associated with COVID-19 are chilblain-like lesions (CBLL), maculopapular lesions, urticarial lesions, vesicular lesions, and livedoid lesions. Other skin findings secondary to SARS-COV-2 infection are erythema multiforme (EM)-like lesions and skin findings associated with multisystem inflammatory syndrome in children (MIS-C) and rarely multisystem inflammatory syndrome in adults (MIS-A). Physician awareness of skin manifestations of SARS-CoV-2 infection can help with early identification and treatment. This narrative review provides an update of various skin manifestations reported with SARS-CoV-2 infection, including clinical presentation, proposed pathogenesis, histopathology, prognosis, and treatment options.

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the zoonotic agent that causes coronavirus disease 2019 (COVID-19). In December 2019, SARS-CoV-2 was first reported in Wuhan, China and has been rapidly spreading through human-to-human transmission worldwide. In March 2020, SARS-CoV-2 was declared a global pandemic by the World Health Organization. SARS-CoV-2 infection is a multisystem disease presenting with dry cough, fever, and fatigue. Other symptoms may include anosmia, arthralgia, gastrointestinal symptoms, headaches, myalgia, nasal congestion, odynophagia, and pneumonia. It affects all age groups with differing degrees of disease severity, ranging from asymptomatic carriers to patients requiring intensive care.

With the increasing number of SARS-CoV-2 cases worldwide, several dermatologic manifestations have been reported in association with SARS-CoV-2 infection. There are online registries, by the American Academy of Dermatology (AAD) and International League of Dermatological Societies (ILDS), in which skin lesions during or following SARS-CoV-2 infection can be reported to help describe the spectrum of SARS-CoV-2-related skin changes.[1] However, Recalcati was the first to report skin manifestations associated with SARS-CoV-2.[2] The estimated incidence of cutaneous manifestations secondary to COVID-19 is between 4 and 20.4%.[3] In an independent survey of 11,544 respondents, Visconti et al. reported 17% of patients infected with SARS-CoV-2 had skin manifestations as their first symptom and 21% as their only clinical sign of illness.[4] Cutaneous manifestations frequently occur during the first 4 weeks from SARS-CoV-2 symptom onset with urticarial and exanthema patterns being most common.[5]

Dermatologic findings are secondary to SARS-CoV-2 binding to angiotensin-converting enzyme-2 (ACE2) receptors found in dermal blood vessels, epithelial cells of eccrine glands, and the basal layer of hair follicles.[6] Galvan-Casas et al. organized 375 cases of skin manifestations related to SARS-CoV-2 infection into the following five groups: chilblain-like lesions (CBLL), maculopapular eruptions, urticarial eruptions, vesicular eruptions, and livedo or necrosis.[7] In addition, a systematic review of 998 patients from nine different countries found that the most common cutaneous patterns were CBLL (402, 40.2%), maculopapular lesions (227, 22.7%), urticarial lesions (89, 8.9%), vesicular lesions (64, 6.4%), and livedoid lesions (28, 2.8%).[8] Other reported skin findings are erythema multiforme (EM)-like lesions and skin findings associated with multisystem inflammatory syndrome in children (MIS-C) and rarely multisystem inflammatory syndrome in adults (MIS-A). The aim of this article is to review various skin manifestations secondary to SARS-CoV-2 infection.

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