At the time of writing, we are in a state of “eased” lockdown; things aren’t as strict as they have been but we should all still stay at home as much as we can and if we must go out, we should practice social distancing and stay 2 metres away from people who are not from our own household. Time will tell if we get a second wave in the next few weeks.
Not surprisingly, we are starting to learn more and more about this new viral pathogen, SARS-COV-2 and the disease it causes called COVID 19 (Coronavirus Disease 2019).
First there were the reports that it not only affects the lungs but can also affect the kidneys. There are reports of the mental health of survivors and healthworkers on the ‘frontline’ being affected. There are reports of a rare inflammatory syndrome in children with COVID 19.
We have also heard and may also have possibly seen reported skin manifestations of COVID 19. The British Journal of Dermatology published a Spanish case collection of skin manifestations in 375 COVID patients last month.
[Galván Casas C, Catalá 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. doi: 10.1111/BJD.19163]
What does it say?
This was a case collection survey involving dermatologists throughout Spain. They were to report all patients with a skin eruption of recent (within the previous two weeks) onset with no clear explanation, plus patients with suspected (ie representative symptoms) or confirmed COVID-19. A standard questionnaire was completed per patient together with pictures.
These pictures were reviewed by a group of four dermatologists with no knowledge of the accompanying clinical information. The skin eruptions were grouped according to the pattern of disease.
What did they find?
They found that that there were five major clinical patterns.
What are these?
19% had lesions that looked like chilblains with purple areas with some vesicles (fluid-filled spots) or pustules (pus-filled spots) on hands and feet. This presentation has been given the name COVID toe.
9% had a widespread eruption of tiny, identical vesicles on their trunk and sometimes limbs (though some could be quite large vesicles).
This vesicular eruption had also been recently reported in another journal.
[Fernandez-Nieto D, Ortega-Quijano D, Jiminez-Cauhe J et al. Clinical and histological characterization of vesicular COVID-19 rashes: A prospective study in a tertiary care hospital. doi: 10.1111/CED.14277]
19% had urticaria-like lesions (like hives) on the trunk.
47% had a maculopapular (flat or slightly raised spots or patches) rash with some scaling that looked similar to a common rash called pityriasis rosea.
6% had something called livedo or necrosis (dead skin).
What does this mean?
The pseudo-chilblain presentation was found typically in younger patients, took place later in the course of the COVID-19 disease and was associated with less severe disease.
The widespread eruption of tiny vesicles, the urticaria-like and maculopapular rash were found in generally older or middle aged patients and were associated with intermediate or more severe disease.
The livedo or necrotic lesions were typically in older patients with more severe disease.
Obviously, the study missed the very mild cases in the general population because they did not present for medical attention or get tested and also the very severe cases due to difficulties in getting consent. Also they did not think that the pseudo-chilblain appearances could be due to cold weather as the pandemic was during a warm weather period.
But can a single virus cause different skin rashes?
Not typically. There is also the possibility that there might have been co-infection with another virus. There is also the possibility that those with more severe disease had been given various different drugs which in themselves can cause a rash.
It is unlikely that any of these rashes will help in the diagnosis of COVID-19. The pseudo-chilblain pattern is striking but occurs late in the disease. However this paper does highlight and attempt to classify the skin manifestations that might be seen in COVID-19 which is helpful.
We still have a lot to learn about this virus and this disease. As I’ve heard on the several webinars I’ve attended on this disease, it truly does seem as if we’re “building the ship as we sail it.”
Dr Sandy Flann