Cutaneous Manifestations of SARS-CoV-2 Infection

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


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

In This Article

Urticarial Lesions

Clinical Presentation

Urticarial lesions are also nonspecific to SARS-CoV-2 infection and may occur with other viral infections. They constitute between 4 and 19% of SARS-CoV-2-associated dermatologic manifestations. These lesions are similar to idiopathic urticaria and predominantly affect the trunk with migratory, pruritic, edematous, variably sized wheals that resolve within 24 hours and leave no bruising or hyperpigmentation (Figure 2). These lesions can be associated with angioedema.[23]

Figure 2.

Pink pruritic edematous wheals on trunk and arms


The pathogenesis of urticarial lesions secondary to SARS-CoV-2 infection involves the following: (i) SARS-CoV-2 binds to ACE2 receptor and enters the cell by endocytosis which disrupts the pathway for ACE2 activity, causing an increase in angiotensin II which results in reactive oxygen species formation, disruption of antioxidant and vasodilatory molecules, and ultimately complement activation;[6] (ii) SARS-CoV-2 induces basophil and mast-cell activation (which has pre-formed inflammation mediators like that of histamine), causing an inflammatory response which leads to these lesions.[13]


The histopathology of urticarial lesions due to SARS-CoV-2 infection resembles that of idiopathic urticaria. These lesions demonstrate perivascular lymphocytic infiltrate, scattered eosinophils, and upper dermal edema with no virally induced cytopathic changes or intranuclear inclusions.[13]


Urticarial eruptions may appear as a prodromal finding with variable timing in patients infected with SARS-CoV-2. These lesions may be present before fever onset or with pyrexia and cough. For example, Rotulo et al. presented a healthy 6-year-old female with fever and pharyngodynia and was positive for SARS-CoV-2 by molecular and antigen tests; she had fleeting urticarial lesions that lasted < 24 h and desquamation of the distal phalanges of the hands and feet.[24] Pagali and Parikh reported a 54-year-old female infected with SARS-CoV-2 who first presented urticarial rash on the trunk for 3 days before developing other SARS-CoV-2 related symptoms.[25]

These lesions are usually an indicator of severe disease. In a Spanish study of patients positive for SARS-CoV-2, 19% had urticarial lesions that lasted for an average of 6.8 days with a severe prognosis, as the mortality rate was 2%.[7] However, the presence of systemic eosinophilia is a predictor of a better prognosis.[13]

It is important to take a detailed medical history as many SARS-CoV-2-positive patients take medications that may cause urticarial lesions. Symptomatic treatment for SARS-CoV-2-associated urticaria is similar to that of acute urticaria consisting of second-generation antihistamines. Low-dose oral steroids could be considered in refractory and severe cases as they target the SARS-CoV-2 cytokine storm, which help prevent mast cell activation and histamine release. Combining antihistamines with steroids can help improve urticaria lesions; however, the immunosuppressive effect of steroids can increase the risk for viral replication, thus, short-term use should be considered.