Skin Manifestations of COVID-19 Infections – An Unusual Symptom

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By Gary Levy, MD, and Daniel A. Vorobiof, MD

Over the past three months, doctors and medical staff dealing with coronavirus-infected patients have documented a growing list of atypical infection symptoms, giving more insight into the COVID-19 disease and its side-effects.

The first reported symptoms included fever, dry cough, shortness of breath, loss of taste and smell, and fatigue/tiredness being the most common presenting features. Body aches and pains, repeated shaking and tremors, a runny or blocked nose, sore throat, abdominal pain, diarrhea, a heightened clotting tendency and neurological symptoms were all noted, too.

With the pandemic spread and the extensive clinical research being conducted worldwide, researchers are observing more and different symptoms, with mounting evidence that the disease presents differently depending on the patient’s age and condition. Many of these less-common symptoms remain rare in incidence, such as multi-system inflammatory syndromes, strokes and blood clots, silent hypoxia, delirium, and dermatological manifestations, but it’s important to be aware of them.

Over a period of just two months, it has become apparently clear that there are many dermatological manifestations of the COVID-19 infection, and it is now estimated that up to 20% of people infected with COVID-19 will develop some sort of skin lesion, with up to 12.5% developing cutaneous manifestations before the onset of respiratory symptoms or the confirmation of a COVID-19 diagnosis.

The most common cutaneous manifestation of COVID-19 is a maculopapular eruption (exanthema), presenting in up to 47% of patients. This can be described as a type of rash characterized by a flat, red area on the skin that is covered with small raised bumps.

The five most common clinical patterns have now been identified as follows:

Maculopapular eruption (47%): 

  • Appears simultaneously to other symptoms
  • It is usually perifollicular
  • Can look very similar to pityriasis rosea
  • Purpura/petechiae may be present (punctate or in large areas) in a smaller number of patients, up to 1.4%
  • The rash may have a lacey pattern
  • There may be infiltrated papules, often on the dorsum of hands, resembling erythema elavatum diutinum or erythema multiforme
  • 75% of these cases are itchy
  • Average duration is 8.6 days
  • Most importantly, it is associated with more severe COVID-19 infections.

Pseudo-chilblain (19%) (now also referred to as “COVID-19 toes”):

  • Late presentation: 59% after other symptoms occur
  • Acral sites, meaning that it appears in peripheral body parts, such as toes and fingers 
  • Usually asymptomatic
  • Seen most often in younger patients
  • Average duration is 7-12 days
  • Associated with less severe COVID-19 infection

Urticarial lesions (19%):

  • Appear simultaneously to other symptoms
  • Mostly truncal (the trunk of the body), in a few cases palmar (in the palm of the hand)
  • 92% of patients with urticarial lesions are itchy
  • Average duration is 6.8 days
  • Associated with more severe COVID-19 infection

Papular-vesicular eruption (9%):

  • It has an early presentation: 15% appear before other symptoms
  • Monomorphic versus polymorphic vesicles 
  • May have a hemorrhagic component
  • Itchy in 68% of cases
  • Average duration of 10.4 days
  • Usually associated with intermediate severity of the COVID-19 infection

Livedo reticularis lesions or necrosis (6%)

  • They haveeither truncal or acral distribution
  • Seen more often in older patients
  • Associated with more severe COVID-19 infections

In summary, it is extremely important that all physicians be made aware of these described associations of dermatological manifestations within the presence of COVID-19 infections, and refer the patients as soon as possible to undergo immediate testing and examinations to confirm the diagnosis of COVID-19 and be treated according to current therapeutic protocols. 

Gary is a Specialist Dermatologist, Johannesburg, South Africa, Daniel is Medical Director of Belong.Life, Tel Aviv, Israel

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