3, 14, 19 Additionally, a systematic review 8 reported a possible link between vesicular eruptions and neurologic symptoms including headache, dysgeusia, irritability, and confusion. Like urticaria, vesicular eruptions were also commonly noted before other COVID-19 symptoms (in 8.5% 3 to 15% 13 of cases of COVID-19-associated urticaria) in multiple studies, and therefore may similarly provide an indication for COVID-19 testing and isolation in the appropriate clinical context. 17 Additionally, while there have been reports of SARS-CoV-2 spike proteins detected with immunohistochemistry in sweat glands and dermal endothelial cells in skin biopsies from COVID-19 patients, 2 studies of COVID-19-associated vesicular rashes detected no SARS-CoV-2 in vesicular fluid by reverse transcriptase polymerase chain reaction testing. 15 However, some reports describe prominent keratinocyte acantholysis contributing to formation of intraepidermal vesicles, which is a relatively unusual histologic finding. Lesional skin biopsies reveal histologic features consistent with viral exanthems, namely vacuolar degeneration of the basal epidermal layer with occasional dyskeratotic keratinocytes and superficial dermal inflammation. ![]() 13 Additionally, an analysis of 200 patients with COVID-19 with cutaneous manifestations 14 found a significant association between urticaria and gastrointestinal symptoms, which could assist clinicians in their anticipatory management. Interestingly, in a systematic review of 895 patients with COVID-19, 13 105 (12%) had urticarial lesions, and in 17 (16%) of these 105 the urticaria began before the onset of the other COVID-19 symptoms, suggesting that it can be a clue to diagnosis in appropriate clinical settings and can help guide early testing ( Figure 2). 9, 10 However, urticarial vasculitis has been described in association with COVID-19, suggesting that biopsy should be considered in patients with persistent urticarial plaques with associated purpura. Histologic features also mimic those of idiopathic urticaria and thus limit the value of skin biopsy. 9, 10 On average, urticaria lasts less than 1 week 11 and is associated with relatively mild disease and survival rates of 97.8% 6 to 98.2%. The clinical features do not appear to differ from those of idiopathic urticaria and typically consist of generalized pruritic wheals. URTICARIA CAN BE THE FIRST SIGN OF COVID-19 Vaso-occlusive lesions (due to thrombosis and occlusion of small arteries, with subsequent ischemia). Pseudo-chilblains (also known as “COVID toes,” painful inflammation of the digits in response to cold) Morbilliform rash (containing macules and papules, resembling measles) Additionally, an analysis of 296 hospitalized patients with COVID-19 in the United States 2 found that mucocutaneous findings were associated with the need for mechanical ventilation, even when adjusted for age, body mass index, and comorbidities.ĬOVID-19-associated cutaneous abnormalities are often grouped into 5 major categories ( Table 1) 3: For example, a study of more than 330,000 community-based patients in the United Kingdom 1 found that patient-reported skin rash was associated with positive COVID-19 testing and was more predictive than fever. It is beneficial to watch for cutaneous manifestations of COVID-19, both in and out of the hospital. The most worrisome manifestations are vaso-occlusive skin lesions, which most often occur in hospitalized patients with COVID-19 and are associated with a poorer prognosis than other skin lesions.Īs experience with caring for patients with COVID-19 has accumulated since the onset of the pandemic, so has our understanding of its associated cutaneous manifestations and their clinical implications. ![]() ![]() The association of pseudo-chilblains with COVID-19 remains controversial, and no definitive evidence linking them to SARS-CoV-2 infection has been reported. Urticarial and vesicular eruptions may precede other COVID-19-associated symptoms and, along with morbilliform rashes, are typically associated with overall high survival rates. The common cutaneous abnormalities that occur in COVID-19 patients were recognized early in the pandemic, and evidence concerning their pathogenesis and clinical relevance continues to accumulate.
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