Classification of the Cutaneous Manifestations of COVID-19

COVID-19’s Myriad Cutaneous Manifestations

Since the novel coronavirus, SARS-CoV-2, entered our awareness with its exponential spread and COVID-19 demonstrated its devastating impact, dermatologists have been wondering what role our field will play in this pandemic. The initial focus involved doing our part to prevent the healthcare system from being overwhelmed: curtailing practices to flatten the curve and preserve personal protective equipment; transitioning to teledermatology to continue safely providing care for dermatology patients while remaining available for those in need; supporting frontline healthcare workers by keeping patients with skin disease out of EDs and primary care offices; and helping those same frontline providers manage PPE-associated skin issues. However, the question of whether there were significant skin issues associated with COVID-19 has persisted over the early months of the pandemic.

This is the paper we have been waiting for. Initial reports from Wuhan suggested cutaneous manifestations were rare.¹ Subsequently, our colleagues in Italy, initially aided by social media discussions, suggested that up to 20% of patients with COVID-19 could have skin findings.² Shortly thereafter, small case reports and series emerged describing a variety of skin findings. Now, Galván Casas et al have provided us with the largest series to date, a prospective study out of Spain, which is not only a large dataset, but also comes with an online image atlas illustrating the spectrum of skin findings we may encounter in evaluating patients during the pandemic. Patients primarily developed maculopapular eruptions, urticarial lesions, and, of course, acral lesions (the pernio-like, or, as these authors note, pseudo-chilblain lesions, which have popularly been referred to as COVID toes). Vesicular eruptions, livedo, and necrosis were observed in subsets of patients as well.

Notably, as with many studies being presented, many of these patients did not have confirmed COVID-19. However, this study involved Spanish dermatologists collecting cases seen prospectively over a 2-week period during the peak of the pandemic, including a questionnaire, photos, and inclusion of patients with new-onset rashes, no alternative explanation, and either known or suspected COVID-19, and likely accurately captures the spectrum of cutaneous involvement that may occur across the severity spectrum of COVID-19.

Even as I write this commentary, the literature continues to evolve almost as fast as the virus spreads, and any commentary will be rapidly outdated. I encourage you all to continue reading. Take time to look at not only this manuscript, but also the accompanying atlas of images, which nicely illustrate the spectrum of disease we can expect to see over the coming months.

References

1. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032
2. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387. [Epub ahead of print.] https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.16387

Dr. Rosenbach is a member of the AAD’s Ad Hoc Covid-19 Task Force, but this commentary represents his own views. He is also involved in the AAD’s Covid-19 registry project under the leadership of Dr. Esther Freeman (https://www.aad.org/member/practice/coronavirus/registry)

This a large multicentric descriptive cohort study of skin eruptions of patients with proven and suspected COVID-19 in Spain. The main objective was to characterize morphological patterns as well as describe associated factors such as demographics, timing of other symptoms, severity, and prognosis of patients. In all, 4 blinded dermatologists reviewed almost 400 clinical photographs from across Spain. They identified five clinical patterns: maculopapular and urticarial patterns were found in almost two-thirds of the patients and were considered nonspecific. Apparently, these patients had severe disease and received medications, increasing the possibility of drug eruption as possible culprits. Livedo pattern and necrosis were uncommon and seen in elderly patients with severe disease, suggesting no utility in diagnosis or prognosis. However, most patients in this study did not have severe disease and were underrepresented. Finally, almost one-third of patients had pseudo chilblains and vesicular eruptions, which apparently seem to be indicators of COVID-19 infection. In this group, pseudo chilblains were asymmetric, presented late in the course of the disease, and were associated with negative PCR results. Only a third of patients reported pruritus or pain. Vesicular lesions tend to appear early in the course of a moderate disease and were associated with pruritus.

Overall, more studies are needed to determine the prevalence of skin eruptions in COVID patients and their clinical significance. This study suggests that pseudo chilblains might have the potential to be a marker of previous infection. It also suggests that vesicular presentations might have the potential to be an indicator of disease, as it has also been suggested in a smaller study from Italy (J Am Acad Dermatol. 2020 Apr 16). However, it is currently unclear whether pseudo chilblains or vesicular patterns should prompt clinicians to seek specific laboratory testing for patients to rule out COVID-19 infection, especially when other seasonal viruses might be concomitantly prevalent depending on weather conditions.