Skin manifestations of COVID-19 – part II

This review includes summaries of some of the latest medical research findings and case reports about the dermatological signs of COVID-19.

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COVID-19-associated pernio/chilblain – or ‘COVID toes’

Case reports

Clinical practice

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>> Skin manifestations of COVID-19 – part I


COVID-19-associated pernio/chilblain – or ‘COVID toes’

Prevalence, clinical relevance, and prognostic value of chilblain-like lesions (CLL)

Based on a systematic review of papers published between December 2019 and 16 June 2020, that described relevant skin changes in patients with suspected or confirmed COVID-19, researchers found the following:

Key findings

  • Available data suggests equal gender distribution, mean age of 21 years, and median age of 14 years.
  • 53% of cases reported mild extracutaneous symptoms. 47% were asymptomatic.
  • CLL occurred an average of 16 days after extracutaneous symptoms.
  • Patients with CLL were positive for SARS-CoV-2 in 15% of cases.
  • Lesions were mainly described as asymptomatic and/or pruritic erythematous to violaceous acral macules and plaques.
  • Partial or complete resolution occurred in 85% of cases in a mean of 13 days.
  • Most common histologic findings: perivascular and perieccrine superficial and deep lymphocytic infiltrates.

>> Access the review in Journal of Cutaneous Medicine and Surgery

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‘COVID-toes’, a cutaneous sign of innate resistance to SARS-CoV-2

Although chilblain-like skin lesions on the toes have been associated with SARS-CoV-2 infection, the majority of these patients do not develop COVID-19 symptoms, and their nasal swabs and serological tests are unable to confirm SARS-CoV-2 infection, despite a clear exposure to the virus.

According to the research authors, evidence suggests that these patients mount a robust type I interferon response to SARS-CoV-2, making them resistant to the infection. ‘COVID-toes’ may therefore represent the skin expression of interferon-mediated resistance to SARS-CoV-2.

The authors suggest that further research is needed to define the mechanisms of COVID-toes which may provide new strategies to promote SARS-CoV-2 resistance.

>> Read the abstract in Revue Médicale Suisse

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Unifying cutaneous and systemic mechanisms may explain COVID-19-associated pernio

Based on a review of the literature published in 2020 on the association between pernio and COVID-19, researchers have speculated that several unifying mechanisms may explain COVID-19‒associated pernio:

Key findings

  • SARS-CoV-2 cell infection occurs through the cellular receptor angiotensin-converting. enzyme 2 mediated by transmembrane protease serine 2, subsequently affecting the renin-angiotensin-aldosterone system with an increase in the vasoconstricting, pro-inflammatory, and prothrombotic angiotensin II pathway.
  • SARS-CoV-2 cell infection triggers an immune response with robust IFN-I release in patients predisposed to COVID-19‒associated pernio.
  • Age and sex discrepancies correlated with COVID-19 severity and manifestations, including pernio as a sign of mild disease, are likely explained by age-related immune and vascular differences influenced by sex hormones and genetics, which affect susceptibility to viral cellular infection, the renin-angiotensin-aldosterone system balance, and the IFN-I response.

>> Read the review in Mayo Clinic Proceedings

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Case reports: severe urticarial rash, pityriasis rosea, and sarcoidal granulomas

Severe urticarial rash as the initial symptom of COVID-19 infection

Presentation – see pictures

A 54-year-old woman presented to the emergency department with a 3-day history of pruritic rash and hives which was then followed by a 1-day history of shortness of breath (hypoxia).

Investigations

  • SARS-CoV-2 COVID-19 PCR testing was positive.

Treatment

  • Oral antihistamines.
  • Antiviral therapy with remdesivir.

Outcome

  • Complete resolution of rash, rash-associated itching and burning sensation, and hypoxia within 48 hours of initiation of therapy.
  • Discharged out of the hospital safely on day 5 of hospitalisation when the antiviral therapy was completed.

Key learnings

  • Cutaneous manifestations are prevalent and on occasions can be the first presenting symptom for COVID-19 infection.
  • Acral lesions and vesicular rashes are noted to be the most common rash types prior to non-cutaneous COVID-19 symptoms. Rarely, urticarial rash can also present prior to other non-cutaneous COVID-19 symptoms.
  • For debilitating symptomatology associated with the rash, consideration should be given to oral antihistamines and topical steroid creams for symptom control.
  • Consideration and role of antiviral therapy with remdesivir for debilitating rash should be further studied and analysed.

>> Read the full case report in BMJ Case Reports

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Pityriasis rosea Gibert triggered by SARS-CoV-2 infection

Pityriasis rosea (PR) Gibert, an erythematous-papulosquamous dermatosis, is frequently associated with episodes of upper respiratory tract infections.

This report describes the case of a 54-year-old female patient in whom the diagnosis of PR led to the investigation and diagnosis of the SARS-CoV-2 infection, suggesting that SARS-CoV-2 may be a new viral trigger of PR.

Presentation – see pictures

  • 3-week of an extremely pruritic erythematous-squamous lesion, initially on the trunk and upper limbs, with extension to the lower limbs in the last week and the lesion respected the cephalic extremity, palms, and soles.
  • It was noted that she had a respiratory tract infection one week before developing the rash.

Treatment

  • Antihistamines and topical medication with corticosteroids.

Outcome

  • Despite the treatment there was further spread of the lesions and accentuation of the pruritis.
  • The patient was subsequently confirmed to have had a SARS-CoV-2 infection.
  • After 7 days of treatment there was partial remission of the lesions.

Key learning

  • There may be an association of PR with SARS-CoV-2 infection, in the context of the pandemic, suggesting the need to test patients with PR skin lesions for SARS-CoV-2 infection.

>> Read the case report in Medicine

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COVID-19-triggered sarcoidal granulomas mimicking scar sarcoidosis

This report describes the case of a 55-year-old woman, with a history of hypertension, hyperlipidemia and hypothyroidism, who has developed a cutaneous manifestation of coronavirus disease where she developed sarcoidal granulomas that showed appearances of scar sarcoidosis.

Presentation – see pictures

  • infiltrated, reddish and tender plaques over old scar sites on both knees.
  • multiple, rounded, mobile and tender subcutaneous nodules of 1–2 cm in diameter on both arms.
  • three subcutaneous papules measuring 3–4 mm on periorbital areas.
  • a single papule in the glabellar region.

History

  • Papules on periorbital and glabellar areas corresponded to the sites of botulinum toxin-A injection that had been performed three months earlier.
  • One month after the first manifestations of COVID-19, she had noticed swelling of her old scars.
  • One month later, small papules appeared at the sites of the botulinum toxin-A injection as well as multiple larger subcutaneous nodules in both elbows.

Investigations

  • Histopathological examination of a punch biopsy from an infiltrated plaque on old scar showed non-necrotic, naked granulomas in the superficial and deep dermis suggestive of a sarcoidal granuloma.
  • There was no sign of systemic sarcoidosis.

Outcome

  • The lesions began to regress spontaneously within one month.
  • At the next visit, which corresponded to 8 months after the diagnosis of infection, facial lesions had resolved, subcutaneous nodules substantially diminished, and the scar lesions become paler with a slight induration.

Key learnings

The authors postulate on possible causes, such as a delayed immunological response, but state that the exact cause of this is not well understood. However, it seems to suggest a relationship between viral infections and sarcoidal granulomatous reactions.

>> Read the case report in Journal of the European Academy of Dermatology and Venereology

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Clinical practice

The rise of teledermatology during COVID-19

The pandemic has fundamentally transformed the landscape of providing dermatology care. In an age of lockdowns and social distancing, the researchers argue in this paper that teledermatology (TD) has emerged as a powerful tool to deliver remote care. For example, it offers greater flexibility and care can be provided synchronously (face-to-face) in a live format and asynchronously (store-and-forward), where images obtained by the patient can be transmitted to the clinician.

Research aim: review the literature on TD use during the pandemic to evaluate the positives and negatives of TD implementation, as well as the potential for TD to occupy a more prominent role in dermatologic care in a post-COVID-19 world.

Key findings

  • TD has been generally positively received during the COVID-19 pandemic.
  • However, numerous challenges for TD implementation exist, from access to TD to ethico-legal considerations.
  • Solutions to circumvent these challenges have emerged during the pandemic and raise the possibility of TD occupying a more central role in the paradigm of dermatology care.

>> Read the review in American Journal of Clinical Dermatology

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