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

Vesicular/Varicella-like Lesions

Clinical Presentation

Vesicular or varicella-like lesions secondary to SARS-CoV-2 occur in both children and adults with a prevalence between 11 and 18%. These lesions are characterized by small, scattered monomorphic vesicles on the trunk with mild or absent pruritus, pain, or a burning sensation. They typically occur 3 days after onset of systemic findings and resolve within 8 days without scarring.


Varicella-like lesions occur due to direct viral effect on keratinocytes. Evidence shows that the SARS-CoV-2 spike protein receptor, ACE2, is expressed in the basal keratinocytes.[13] SARS-CoV-2 binding to ACE-2 increases acantholysis and dyskeratosis.


The histopathology of varicella-like lesions is similar to those of viral infections. Early lesions have basal layer vacuolar degeneration as well as multinucleated and hyperchromatic keratinocytes with dyskeratotic apoptotic cells and minimal to absent inflammatory infiltrate.[13,26] Late lesions are similar to herpetic lesions or pseudo-herpetic Grover's disease and show intraepidermal unilocular vesicles containing multinucleated and ballooned keratinocytes with acantholytic and dyskeratotic cells as well as epidermal reticular degeneration.[13]


The prognosis of varicella-like lesions for patients infected with SARS-CoV-2 is variable. In a study of 22 Italian patients who tested positive for SARS-CoV-2, Marzano et al. reported varicella-like lesions on the trunk which developed 3 days after symptoms and lasted for 8 days without scarring; the mortality rate of this cohort was 13.6%.[26] In a case report by Genovese et al., a SARS-CoV-2-positive 8-year-old female had multiple varicella-like lesions that developed 3 days post-onset of symptoms; these lesions resolved without treatment in 7 days.[27]

There is no standard treatment for varicella-like lesions and a "wait-and-see" strategy is recommended.[22] Generally, treatment for these lesions is supportive. They self-resolve within several days without scarring.