Call to Action for Reporting Cutaneous Manifestations of COVID-19

Respiratory symptoms, fever, fatigue, chills, and aches are the well-documented diagnostic features of coronavirus disease (COVID-19). Early reports from China indicated only 0.2% of patients with laboratory-confirmed COVID-19 presented with rash,¹ and there were scant case reports involving “generalized sporadic erythema,”² skin bulla,³ and petechial rash.⁴ As the pandemic continued to spread across the globe, the awareness of cutaneous manifestations of COVID-19 began to increase. Dermatologists, now involved in triage stations and medical wards in countries such as Italy and Spain, used their trained eyes to see changes in the skin that other specialties would not have paid any attention.

A letter to the editor in Journal of the European Academy of Dermatology and Venereology stated 20.4% (18/88) of patients developed skin involvement, including eight patients at onset.⁵ Presentation included erythematous rash, widespread urticaria, and chickenpox-like vesicles, with the trunk most often affected and with low or absent pruritus. In addition, Marzano et al⁶ described 22 patients with papulovesicular lesions. In a recent virtual mini-symposium hosted by the Medical Dermatology Society and the Society of Dermatology Hospitalists COVID-19 Joint Task Force, Joanna L. Harp, MD, of Weill Cornell Medicine in New York, NY, noted seeing acral-livedo racemose/retiform purpura in hospitalized patients.⁷

Notably, the manifestation that has received the most attention as of late is COVID toes, a sort of layman term for the pernio-like lesions presenting in a majority of patients in the latest literature.^8-13 Further, in a series of 375 cases, the authors reported that vesicular eruptions appear early in the course of disease, while pernio-like lesions tend to appear late in the evolution of COVID-19.¹⁴ 

The recent literature highlights the critical point of the American Academy of Dermatology (AAD) COVID-19 Dermatology Registry.¹⁵ The AAD registry is intended for HCPs providing care to either patients with COVID-19 who develop dermatologic manifestations or patients with an existing condition (eg, psoriatic disease) who then developed COVID-19. The de-identified, confidential form takes roughly 5 to 7 minutes to complete, and information shared will only be accessible by the research group.

As research continues to find more clinical manifestations of COVID-19, dermatology is doing its part to help decode what the virus does to the human body. Dr Esther Freeman is the principal investigator of the COVID-19 Dermatology Registry, built in collaboration with the American Academy of Dermatology and the International League of Dermatologic Societies. She explained the importance of the AAD's registry and resources for dermatologists with The Dermatologist.

Understanding the dermatologic signs of COVID-19 will help elucidate whether pernio-toes, papulovesicular lesions, retiform purpura, or another underreported manifestation are legitimate diagnostic features of the disease. Participation in the registry has the potential to help clarify diagnostic criteria and guide future therapies, with the ultimate goals of diagnosing COVID-19 sooner, reducing the disease burden, and improving patient outcomes.

To see the latest in research regarding cutaneous manifestations of SARS-CoV-2 infection, visit our COVID-19 Research Roundup. You can also visit the COVID-19 Care360 site from our sister publication, Consultant 360. 

References
1. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. New Engl J Med. 2020;382:1278-1280. doi:10.1056/NEJMc2001899

2. Lu S, Lin J, Zhang Z, et al. Alert for non-respiratory symptoms of coronavirus disease 2019 (COVID-19) patients in epidemic period: a case report of familial cluster with three asymptomatic COVID-19 patients. J Med Virology. Published online March 19, 2020. doi:10.1002/jmv.25776

3. Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patient with critical COVID-2019 pneumonia and acro-ischemia [in Chinese]. 2020;41:E006. doi:10.3760/cma.j.issn.0253-2727.2020.0006

4. Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol. 2020;82(5):e177. doi:10.1016/j.jaad.2020.03.036

5. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective.  J Eur Acad Dermatol Venereol. Published online March 26, 2020. doi:10.1111/jdv.16387

6. Marzano AV, Genovese G, Fabbrocini G, et al. Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients. J Am Acad Dermatol. Published online April 16, 2020. doi: 10.1016/j.jaad.2020.04.044

7. @RoxanaDaneshjou. Dr. Harp has NOT been seeing COVID toes or pernio-like lesions, urticaria, or vesicular lesions in HOSPITALIZED patients. For hospitalized patients: more acral-livedo racemosa (retiform purpura) -- all critically ill, appearing in week 2-3.  #dermtwitter #medtwitter #COVIDderm. April 30, 2020. Accessed May 6, 2020. https://twitter.com/RoxanaDaneshjou/status/1256008589296074752

8. Fernandez-Nieto D, Jimenez-Cauhe J, Suarez-Valle A, et al. Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak. J Am Acad Dermatol. Published online April 24, 2020. doi: 10.1016/j.jaad.2020.04.093

9. Piccolo V, Neri I, Filippeschi C, et al. Chilblain‐like lesions during COVID‐19 epidemic: a preliminary study on 63 patients. J Euro Acad Dermatol Venereol. Published online April 24, 2020. doi:10.1111/jdv.16526

10. Landa N, Mendieta-Eckert M, Fonda-Pascual P, Aguirre T. Chilblain-like lesions on feet and hands during the COVID-19 pandemic. Int J Dermatol. Published online April 24, 2020. doi:10.1111/ijd.14937

11. De Masson A, Bouaziz JD, Sulimovic L, et al. Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospectice nationwide study from France. J Am Acad Dermatol. Published online May 4, 2020. doi:10.1016/j.jaad.2020.04.161

12. Colonna C, Monzani NA, Rocchi A, Gianotti R, Boggio F, Gelmetti C. Chilblains-like lesions in children following suspected Covid-19 infection. Pediatr Dermatol. Published online May 6, 2020. doi:10.1111/pde.14210

13. López-Robles J, de la Hera I, Pardo J, Martínez J, Cutillas-Marco E. Chilblain‐like lesions: a case series of 41 patients during the COVID‐19 pandemic. Clin Exp Dermatol. Published online May 5, 2020. doi:10.1111/ced.14275

14. Galván Casas C, Català A, Carretero Hernández G, et al. Classification of the cutaneous manifestations of COVID‐19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. Published online April 29, 2020. doi:10.1111/bjd.19163

15. COVID-19 Dermatology Registry. American Academy of Dermatology. Accessed May 6, 2020. https://www.aad.org/member/practice/coronavirus/registry