By Gina B. Rainwater, M.D.

As of May 4, 2020, the number of COVID-19 cases caused by SARS-CoV-2 virus exceeded 1 million in the US and 3 million worldwide. Several unique clinical features are emerging as our knowledge of SARS-Cov-2 viral infection grows. Even though SARs-CoV-2 has lower case fatality rate compared to SARS and MERS, it is not only more infectious, but it also appears to be a multi-organ disease in a subset of patients. While the respiratory system and lungs are the primary and likely early sites of infection, COVID-19 patients have also been reported to develop coagulopathies, thrombotic/ischemic events, acute cardiac injury, arrhythmias, renal dysfunction, diarrhea, seizures, strokes, and conjunctivitis. Over the past few weeks, many reports of cutaneous manifestations/associations of COVID-19 appeared in medical literature. What’s most striking about skin manifestations of COVID-19 reported to date is their heterogeneity. A recent and largest case study of 375 cases from Spain reported five main clinical patterns (see Figures):

Interestingly, pseudo-chilblain lesions were more common in younger, healthier, and frequently asymptomatic patients. Patients with maculopapular and urticarial eruptions had more severe symptoms and were more likely to receive medications than patients with other skin manifestations. Livedoid and necrotic lesions were seen in older and more critically ill patients, and were associated with higher mortality (10%). Transient and unilateral livedo reticularis has also been reported in patients with mild symptoms (see figure).

Transient livedo-2

Transient livedo-2

As we continue to gather and analyze clinical knowledge about COVID-19 associated cutaneous eruptions, it is important to remember that many of these case reports and case studies were produced and published without undergoing traditional peer-review process and scrutiny to satisfy the need for rapid dissemination of information. Moreover, not all reported cases were serologically confirmed. It is likely that many of the skin manifestations seen in COVID-19 patients represent secondary cutaneous changes in the setting of critical illness, coagulopathy/DIC, and multiple medications. It is difficult to definitively conclude at this time if there is a SARS-Cov-2-specific cutaneous eruption. More rigorous, controlled studies and observations are needed to better characterize the heterogeneity of cutaneous manifestations associated with COVID-19. As dermatologists and dermatopathologists, it is important for us to maintain a high level of clinical suspicion for COVID-19 infections as we encounter patients with new onset chilblain-like acral lesions, vesicular, morbilliform, urticarial, and livedoid eruptions, and provide prompt referral for appropriate testing and management.

Pseudo-chilblain-1

Psuedo-chilblain-1

Maculopapular-1

Urticarial-1

Livedoid/Necrotic-1

Vesicular-1

References:

1. Galván Casas C et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. (2020)
2. Manalo IF, Smith MK, Cheeley J, Jacobs R. A Dermatologic Manifestation of COVID-19: Transient Livedo Reticularis. J Am Acad Dermatol. 2020 Apr 10.
3. Meredith Wadman, Jennifer Couzin-Frankel, Jocelyn Kaiser, Catherine Matacic. How does coronavirus kill?Clinicians trace a ferocious rampage through the body, from brain to toes. Online publications. Sciencemag.org Apr. 17, 2020

About the author

Gina B. Rainwater, M.D.

-Board-certified in Dermatopathology by the American Boards of Pathology and Dermatology, and Dermatology by the American Board of Dermatology

-Sub-Specialty Concentration in Clinical Dermatology, Inflammatory Disorders of the Skin, and Pediatric Dermatopathology