What your doctor is reading on Medscape.com:
MAY 08, 2020 — The skin manifestations of the novel coronavirus SARS-CoV-2 were not recognized at the early stages of the pandemic but have received much recent attention in scientific journals and global media outlets. Reported manifestations range from pseudo-chilblains to a morbilliform (measles-like) exanthem, urticaria, vesicular eruptions, a dengue-like petechial rash and ovate scaling macules, and plaques mimicking pityriasis rosea.
The New ‘Great Mimicker’
Much like with HIV and syphilis, COVID-associated “rashes” seem to be as numerous as they are hard to pin down. The largest published study to date is a nationwide case series in Spain with 375 cases which identified five clinical patterns. Because of the scarcity and low sensitivity of diagnostic tests available, the investigators accepted patients with confirmed disease as well as those with a clinical diagnosis of COVID in the study. Just under half (41%) of patients with pseudo-chilblains had confirmed infection with positive viral cultures and/or serology.
Observed COVID-associated skin patterns were:
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Acral erythema with vesicles or pustules; so-called “pseudo-chilblains” (19%)
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Vesicular (chicken pox-like) eruptions (9%)
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Maculopapular eruptions (47%)
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Urticaria (19%)
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Livedo or necrosis (6%)
These investigators found that the vesicular eruptions appeared earliest in the course of COVID-19, prior to any other symptoms in 15% of cases; these developed on the trunk and extremities, were most common in middle-aged adults, and typically lasted around 10 days.
In contrast, the pseudo-chilblains eruption which has received much attention on social media (using the hashtag #COVIDtoes) occurred later. In almost two thirds (59%) of patients, these lesions developed after other symptoms. Despite much concern in the lay press about lesions on toes (which can also, less frequently, present on fingers), pseudo-chilblains acral lesions correlated with a milder disease course and younger patient age. Livedo and necrosis, however, indicated more severe illness and a poor prognosis.
Patients with maculopapular exanthems (47% of reported cases in this series) also had more severe infections and typically manifested skin findings at the same time as other COVID-19 symptoms.
Sounding the Alarm in Kids
Continued
In a recent and alarming twist, more than a dozen children—the group once thought to be most immune to severe COVID complications—have presented in the United Kingdom with a multisystem inflammatory condition with features of toxic shock syndrome and atypical Kawasaki disease. Kawasaki-like signs of this “SARS-CoV-2-related inflammatory syndrome” include an erythematous rash, conjunctivitis and glossitis with high fever, abdominal pain and gastrointestinal symptoms, and cardiac inflammation. Another 25 children with similar findings have been identified in France.
Some of these children have tested SARS-CoV-2 positive or had serologic evidence of prior SARS-CoV-2 infection. These findings prompted a warning from the National Health Service and the Paediatric Intensive Care Society.
A similar alert was just issued by the New York City Health Department after 15 children, ages 2-15, were hospitalized in NYC between April 17 and May 1 with illnesses compatible with this syndrome (ie, typical Kawasaki disease, incomplete Kawasaki disease, and/or shock). Polymerase chain reaction (PCR) testing for SARS-CoV-2 was positive in four of the NY children. As of May 6, 2020, the reported number of children affected in New York had risen to 64 and