Cutaneous Manifestation in COVID-19: A Lesson Over 2 Years Into the Pandemic.

Cutaneous manifestations related to Coronavirus Disease-19 (COVID-19) have been reported over 2 years since the pandemic began. This research aimed to review articles published in English that describe cutaneous manifestations related to COVID-19/SARS-CoV-2. A data search for case reports, original studies, and review articles from the onset of the current COVID-19 pandemic to December 31, 2022, was performed using PUBMED, Cochrane Library, ResearchGate, and Google search engines. Keywords were "coronavirus", "novel coronavirus 2019", "COVID-19", "SARS-CoV-2", and "2019-nCoV" in combination with "cutaneous", "skin" and "dermatology" The extracted data included authors, region, sex, age, number of participants with skin signs, cutaneous signs, its location, symptoms, extracutaneous/associated symptoms, suspected or confirmed status for COVID-19, timeline, and healing duration. Six authors independently reviewed the abstracts and full-texts to identify publications providing these details concerning cutaneous manifestations related to COVID-19. A total of 139 publications with full text (122 case reports, 10 case series, and 7 review articles) that reported cutaneous manifestations were identified, and reviewed from 5 continents. The most common cutaneous manifestations of COVID-19 were maculopapular, followed by chilblain-like lesion, urticarial, livedoid/necrotic, vesicular, and other/non-descript rashes/skin lesions. After 2 years into the COVID-19 pandemic, we can conclude that there is no pathognomonic cutaneous manifestation of COVID-19, since it can be also found in other viral infections.

Cutaneous Manifestations Associated with COVID-19 Infection in a COVID-Designated Hospital in North Chennai - A Descriptive Cross-Sectional Study.

Background: Coronavirus disease 2019 (COVID-19) affects different organ systems, including the skin. There are reports on cutaneous manifestations of COVID-19 available in the literature. In this study, we have tried to describe the dermatological signs of COVID-19 in different categories of patients. Materials and Methods: A descriptive cross sectional study was conducted to describe various cutaneous manifestations of COVID-19 in different categories of reverse transcriptase polymerase chain reaction (RT-PCR)-positive COVID-19 patients in a COVID-designated tertiary care hospital. Approval was obtained from the Institutional Ethical Committee, and 5460 RT-PCR-confirmed COVID-19-positive patients were included under five categories. Investigators following a strict COVID protocol examined and documented the findings. Investigations and treatment were carried out as per the protocol, and the study was conducted for a period of 6 months. Results: Out of the 5460 patients studied, 1.9% patients had cutaneous manifestations. Vasculitis (24%) and maculo papular rash (19%) were the common findings. The incidence of vasculitis was 44.4%, 61%, and 6.6% in categories A, B, and C, respectively. Maculopapular rash and urticaria were the common findings in categories D and E, respectively. COVID digit was seen in only one case. Other manifestations such as acne, adverse drug reaction, erythroderma, and bullous disorders were also noted. Conclusion: Cutaneous manifestations because of vascular pathology were the most common association in severe COVID-19, which indicates that the presence of vasculitic skin signs correlated with disease severity and elevated d-dimer values. Urticaria and maculo-papular rash were transient and did not give any clue to the diagnosis or severity of the disease.

A systematic review on mucocutaneous manifestations of COVID-19 in children

Background: About 20% of patients with coronavirus disease 2019 (COVID-19) present with mucocutaneous eruptions. Early skin or dermatological manifestations can help pediatricians prevent the spread of the disease by suspecting COVID-19 in asymptomatic or minimally symptomatic patients. Method(s): PubMed, Scopus, Embase, Google Scholar, and the Nottingham University website were searched on Sep. 1st, 2020, to retrieve studies regarding COVID-19-related mucocutaneous manifestations in patients under the age of 18. Result(s): Data were extracted from 76 articles including 38, 387 cases. Chilblain/pernio-like lesions were the most common dermatological manifestation, followed by multisystem inflammatory syndrome in children (MIS-C)/Kawasaki-like syndrome. Most dermatological signs were self-limited, presenting before, simultaneously with, or after other COVID-19 manifestations. In 40% of the affected children, these signs were the sole presentation of COVID-19. Conclusion(s): During the COVID-19 pandemic, each new mucocutaneous event in children, especially acral lesions with vascular color, should be considered a possible indicator of COVID-19. Copyright © 2022 Iranian Society of Dermatology.

COVID arm as a common cutaneous manifestation after mRNA-1273 vaccination: a systematic review.

BACKGROUND: By August 2022, CoronaVirus Disease-2019 (COVID-19) had caused 600 million illnesses and 6.5 million fatalities globally. A massive vaccination program is being implemented worldwide to suppress this condition. Several works of literature stated that mRNA COVID-19 vaccination, specifically with the mRNA-1273 vaccine, is followed by clear evidence of the COVID arm effects associated with this vaccine. OBJECTIVE: To analyze the latest evidence of COVID arm as a common effect of mRNA-1273 vaccination with the ultimate goal of improving vaccine counseling to help healthcare professionals and reassure patients. METHODS: A comprehensive search was performed on topics that assess the COVID arm as a cutaneous manifestation following mRNA-1273 vaccination from inception up until July 2022. RESULTS: Eighteen studies with a total of 1129 participants after the first and second dose of mRNA-1273 vaccination reported that most participants had COVID arm following the first dose administration. The characteristics of the patients were a mean age of 43.8 years old, and females represented ≥ 50% in most studies, with a mean onset of 6.9 days after the first dose administration. Symptoms resolved within seven days following the treatment and were harmless. CONCLUSIONS: This study found that the COVID arm condition is most common following the first mRNA-1273 vaccination in the female and middle-aged group. The correlation between demographic variables and COVID arm risk elucidates that the reaction is a type IV allergic skin reaction.

Cutaneous involvement in COVID-19 patients

The ongoing coronavirus disease 2019 (COVID-19) outbreak was declared a pandemic by the World Health organization in early March 2020. The disease typically presents with viral respiratory symptoms that could progress to acute respiratory dis-tress syndrome. Emerging evidence suggests different possible dermatologic manifestations of COVID-19, including: acral lesions (pernio-like, pseudo-chillblain), vesicular eruptions, macular and papular exanthema, urticaria, livedoid, purpuric and petechial rashes. However, specific skin manifestations of the COVID-19 disease have not yet been clearly established and the relationship between the appearance of skin lesions and SARS-CoV-2 infection is still unclear. These highly variable skin changes could represent a direct con-sequence of the viral infection, an immunological response to viral nucleotides, adverse reactions to drugs frequently used for the treatment of COVID-19, or other disorders. In a global effort to comprehend the exact cutaneous features of COVID-19, several international dermatological societies have initiated nationwide studies to analyze COVID-19 cutaneous manifestations during this pandemic. This paper represents a literature review of the scientific data available on the clinical characteristics and symptoms of the cutaneous manifestations associated with COVID-19. Such findings are extremely useful in establishing if dermatological manifestations in COVID-19 patients could harbor a diagnostic significance and subsequently be used as prognostic factors for outcomes of COVID-19. © 2020, Amaltea Medical Publishing House. All rights reserved.

Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic.

Cutaneous vasculitides encompass a heterogeneous group of clinicopathological entities, which may occur as single-organ vasculitis of the skin or present as skin-limited variant of systemic vasculitis (i.e., skin-limited ANCA-associated vasculitis), and are triggered by various factors, including infections, drugs and vaccines. The COVID-19 pandemic has challenged us with a variety of both disease- and vaccine-associated skin manifestations, including vasculitis. Among the latter, cutaneous small-vessel vasculitis, previously known as leukocytoclastic vasculitis, seems to be the most reported in either scenario, i.e., natural infection and vaccination. Vasculopathy without true vasculitic changes on histology develops in but a minority of cases, mostly severe/critical COVID-19 patients, and appears to be the result of endothelial injury due to pauci-immune thromboembolic mechanisms. Herein, we provide an overview of the available literature on COVID-19-associated and anti-SARS-CoV-2-vaccine-associated cutaneous vasculitis. Although evidence is mostly limited to isolated reports, with a proportion of cases lacking histopathological confirmation, ample overlap with pre-pandemic forms is shown.

Cutaneous manifestations of coronavirus disease 2019 patients in Japan.

Some patients with coronavirus disease 2019 (COVID-19) develop skin manifestations. There may be regional and racial differences in the frequency and type of COVID-19-associated skin manifestations. There are, however, few reports on skin manifestations in COVID-19 patients in Asia, including Japan. We retrospectively investigated the frequency, type, and clinical course of skin manifestations in Japanese patients with COVID-19. From 22 February 2020 to 16 August 2021, 738 Japanese patients (median age 59 years, 55% male) with laboratory-confirmed COVID-19 on polymerase chain reaction or antigen tests were admitted to our hospital. We mainly admitted patients with mild to moderate severity who had symptoms such as cough, fever, and oxygen demand but did not require mechanical ventilation. A total of 2.8% (21/738) of the COVID-19 patients treated at our hospital were diagnosed with viral eruptions caused by COVID-19. Of the 21 patients, 19 developed erythematous papules, and two developed urticaria. There were no cases of pernio-like lesions, known as COVID toes. The median duration from the onset of other COVID-19 symptoms to the development of skin manifestations was 9 days. This study revealed that approximately 2-3% of Japanese patients with COVID-19 developed COVID-19-associated viral eruptions, most of which were erythematous papules.

Coronavirus Disease 2019 (COVID-19) and Ecchymosis: A Case Report.

Extrapulmonary symptoms such as cutaneous manifestations are increasingly being reported in coronavirus disease 2019 (COVID-19) infection. The rashes of COVID-19 are usually livedo and purpuric and have been classified into six main patterns. This is the first case reported in Malaysia of ecchymosis associated with COVID-19 occurring on a patient without prior history of coagulopathy. The report of this rare clinical association could have a potential pathophysiological implication and contributes to the current data of the cutaneous manifestations of COVID-19. Further knowledge regarding these cutaneous lesions could help in the diagnosis of COVID-19 related complications and earlier management.

Concomitance or consequence? Stevens-Johnson syndrome in COVID-19: A case report.

The novel coronavirus infection has been, and still is, a pressing medical problem with a catastrophic effect, not only from a medical point of view, but also from an economic and social one. The cutaneous manifestations of the disease have a diverse morphology and can signal the presence of the infection. The present article reports the case of a 77-year-old male patient admitted at The Sf. Parascheva Clinical Hospital of Infectious Diseases in Iasi (Romania) after testing positive for SARS CoV-2 infection. Initially, the patient presented a pruriginous generalized maculopapular-erythematous eruption with a tendency towards confluence, peri-oro-nasal meliceric crusts and desquamation of the skin on the third anterosuperior and posterior thorax, scalp and forehead, which was accompanied by low back pain, headache and orbital pain. The suspicion of Stevens-Johnson syndrome (SJS) was raised, and treatment was given according to the recommendation of the hospital dermatologist. This association raises multiple questions regarding whether SJS is a cutaneous manifestation of COVID-19 or if there was a concomitance between the viral infection and the immune reaction. The combination of SJS and COVID-19 can have a fatal outcome if not recognized and promptly treated. To our knowledge, this is the first case of SJS in a patient diagnosed with SARS CoV-2 infection in Romania.

Histopathology and immunophenotyping of late onset cutaneous manifestations of COVID-19 in elderly patients: Three case reports.

BACKGROUND: Several cutaneous manifestations such as urticarial rash, erythematous patches and chilblain-like lesions have been described in young adults with coronavirus disease 2019 (COVID-19) and are present in up to 20% patients, but few reports exist describing histopathological and immunophenotypic characteristics of dermatological lesions in older patients. Our aim was to characterize skin lesions in elderly patients during late stages of COVID-19 from clinical, histological and immunophenotypic perspectives. CASE SUMMARY: Three patients, admitted for COVID-19, and who developed cutaneous manifestations underwent skin biopsies. Immunophenotypic analysis for CD20, CD3, CD4 and CD8 was performed on skin biopsies to assess immune cell infiltrates. CD1a was used as a marker of Langerhans cells, and CD31 as a marker of endothelial cells. In the three study patients, cutaneous manifestations were evident in the late-stage of COVID-19 (mean time from the first positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab to rash onset was 35 d). Skin biopsies showed a similar pattern of T lymphocyte infiltration in all patients. Indeed, a chronic dermatitis with perivascular lymphocytic infiltrate was observed with predominance of CD3+ T-cell (CD3+). CONCLUSION: Our study confirms previous reports. Histological and immunophenotypic patterns in our patients confirm results described in the two previous reported experiences. This pattern is similar to what is found in some lympho-proliferative disorders. Therefore, since these findings are non-specific, SARS-CoV-2 infection should be suspected.

Cutaneous hemorrhagic bullae in a patient with COVID-19: A case report.

COVID-19 was first discovered in Wuhan, China, and has spread rapidly around the world. The most important manifestation of COVID-19 was ARDS-like lung injury at first, but the involvement of other organs, such as kidney, heart, liver, and skin, was gradually reported. It is important to report and share all atypical manifestations of this disease to help other physicians to gain more knowledge about this new viral disease. As mentioned, there are also studies that show different types of cutaneous involvement in these patients, but due to the lack of more detailed studies in this field, and on the other hand, the possible usefulness of skin lesions as a diagnostic or alarming sign in the COVID-19 era, in this study we report a COVID-19 patient with a large hemorrhagic blister similar to sepsis-induced skin lesion. Despite the lack of common symptoms of the disease, the lung scan of the patient was positive for COVID-19.

Ecchymosis in critical coronavirus disease 2019 (COVID-19) patient in Tangerang, Indonesia: a case report.

We have read with great interest the articles regarding cutaneous manifestations in Coronavirus Disease 2019 (COVID-19) infection. Studies showed 20.4% of COVID-19 patients developed cutaneous manifestations. COVID-19 causes vascular endothelial injury, vasculitis and prothrombotic state which might be the underlying cause of hemorrhagic cutaneous manifestations, disseminated intravascular coagulation (DIC), and multiple organ failures. To date, hemorrhagic cutaneous manifestations reported are chilblain-like lesion, purpura to ecchymosis, livedo reticularis, and dry gangrene. We present a case of ecchymosis in COVID-19-positive ICU hospitalized patient.

Cutaneous manifestations and considerations in COVID-19 pandemic: A systematic review.

COVID-19 had a great impact on medical approaches among dermatologist. This systematic review focuses on all skin problems related to COVID-19, including primary and secondary COVID-related cutaneous presentations and the experts recommendations about dermatological managements especially immunomodulators usage issues. Search was performed on PubMed, Scopus, Embase and ScienceDirect. Other additional resources were searched included Cochrane, WHO, Medscape and coronavirus dermatology resource of Nottingham university. The search completed on May 3, 2020. Three hundred seventy-seven articles assigned to the inclusion and exclusion groups. Eighty-nine articles entered the review. Primary mucocutaneous and appendageal presentations could be the initial or evolving signs of COVID-19. It could be manifest most commonly as a maculopapular exanthamatous or morbiliform eruption, generalized urticaria or pseudo chilblains recognized as "COVID toes" (pernio-like acral lesions or vasculopathic rashes). During pandemic, Non-infected non-at risk patients with immune-medicated dermatologic disorders under treatment with immunosuppressive immunomodulators do not need to alter their regimen or discontinue their therapies. At-risk o suspected patients may need dose reduction, interval increase or temporary drug discontinuation (at least 2 weeks). Patients with an active COVID-19 infection should hold the biologic or non-biologic immunosuppressives until the complete recovery occur (at least 4 weeks).

Cutaneous manifestations in hospitalized patients diagnosed as COVID-19.

Cutaneous manifestations of COVID-19 disease have not yet been fully described. To describe cutaneous manifestations of COVID-19 disease in hospitalized patients. We examined the cutaneous manifestations of 210 hospitalized patients. Cutaneous findings were observed during COVID-19 infection in 52 of the patients. Lesions may be classified as erythematous scaly rash (32.7%), maculopapular rash (23%), urticarial lesions (13.5%), petechial purpuric rash (7.7%), necrosis (7.7%), enanthema and apthous stomatitis (5.8%), vesicular rash (5.8%), pernio (1.9%), and pruritus (1.9%). Cutaneous manifestations were observed statistically significantly more in certain age groups: patients of 55 to 64 and 65 to 74 years of age complained of more cutaneous manifestations than the other age groups. As for gender, there was no significant difference between male and female patients in terms of cutaneus findings. The relationship between comorbidity and dermatological finding status was statistically significant. The relationship increases linearly according to the comorbidities. According to the statistical results, the patients who were hospitalized in the intensive care unit had a higher risk of having cutaneous findings due to COVID-19 infection. With this study, we may highlight the importance of overlooked dermatological findings in patients that are hospitalized.

Dermatological findings in SARS-CoV-2 positive patients: An observational study from North India.

A novel coronavirus (severe acute respiratory syndrome corononavirus-2; SARS-CoV-2) has affected millions of people across the world. The coronavirus disease (COVID-19) resulting from SARS-CoV-2 manifests in variable clinical severity, featuring both respiratory and extra-respiratory symptoms. Dermatological manifestations of COVID-19 are sparsely reported. To study the various dermatological findings in SARS-CoV-2 positive patients in Indian population. Institutional ethical committee permission was sought and102 SARS-CoV-2 positive patients were included in the study. A thorough clinical examination was done to determine the nature and frequency of various dermatological manifestations in these patients. Out of the 102 positive cases, 95 were males. The mean age of the group was 39.30 years. Thirteen patients (12.7%) were found to have dermatological manifestations. Three (2.9%) had maculopapular rash, two (1.9%) had urticarial lesions and eight (7.8%) patients had itching without any specific cutaneous signs. Trunk was the most frequently affected area, followed by the extremities. No mucosal signs and symptoms were detected. Dermatological manifestations were seen in a small group of COVID-19 patients. The presentation may vary in different population groups and based on severity of disease.

Viral exanthem with "Spins and needles sensation" on extremities of a COVID-19 patient: A self-reported case from an Indonesian medical frontliner.

Cutaneous manifestation is a newly reported clinical manifestation of COVID-19 infection. The clinical description of cutaneous manifestation is still not fully described. Our patient, a medical person, had viral exanthem distributed in the extremities along with a "Spins and needles sensation," which differs from a previously published paper on cutaneous manifestations. The differential diagnosis of drug-induced skin rash and hand-foot-mouth disease was ruled out based on the patient's previous history and course of the disease.