Cutaneous manifestations in COVID-19: A case series from a hospital in an area with high infection rates

ABSTRACT

Cutaneous manifestations of COVID-19 infection have been described in the literature since the onset of the pandemic. No formal classification system has been suggested, but cases reported in the literature demonstrate various subtypes, including urticarial, maculopapular, papulovesicular, purpuric and livedoid lesions. The pathogenesis of the cutaneous response is not fully understood, but may represent inflammatory and thromboinflammatory processes. Our institution in South London has treated one of the largest numbers of inpatients with confirmed COVID-19 infection in the U.K., with 2989 cases recorded between 1 February 2020 and 29 June 2020. We describe the spectrum of cutaneous disease associated with COVID-19 infection presenting to an acute liaison dermatology service over a 4-month period from March to June 2020. From a large number of referrals of COVID-19-positive patients with skin disease, 13 cases of cutaneous presentations thought to be caused by COVID-19 infection were identified [eight males, five females;mean age 44 years (range 15-59)]. We included cases from outpatient (n = 8), inpatient (n = 2) and intensive care (n = 3) departments. Eight of 13 had positive COVID-19 antigen testing, while five of 13 had symptoms indicative of COVID-19 infection but were not offered a test. Clinical manifestations included perniosis (n = 3), livedo (n = 2), urticaria (n = 2), maculopapular exanthema (n = 2), vasculitis (n = 1), panniculitis (n = 1), eccrine squamous syringometaplasia (n = 1) and digital vein thrombosis (n = 1). Five of 13 had a skin biopsy that supported the clinical diagnosis. Skin disease in COVID-19 infection reflects viral exanthematous inflammation in many cases. Thromboinflammatory pathologies also contribute to some COVID-19 dermatoses. Vascular and vaso-occlusive pathologies occur prominently in the lungs and kidneys, as well as the skin, and appear to have pathogenetic specificity for COVID-19. Immunostaining of lung tissue with an antibody to the Rp3 NP protein of severe acute respiratory syndrome-coronavirus 2 has revealed prominent expression on alveolar epithelial cells. Immunostaining of skin sections might provide further evidence for a direct viral effect in COVID-19 dermatoses. Our findings are comparable with those of European colleagues regarding the spectrum, the latency and the duration of the cutaneous symptoms. We would like to add our description of three new cutaneous manifestations of COVID-19 infection - panniculitis, eccrine squamous syringometaplasia and digital vein thrombosis - to the body of literature on this topic.