Dermatologic Findings in COVID-19

Authors: Brit Long, MD (@long_brit, Attending Emergency Physician, San Antonio, TX) and Michael Gottlieb, MD (@MGottliebMD, Attending Emergency Physician, Ultrasound Fellowship Director, Rush Medical Center) // Reviewed by: Alex Koyfman, MD (@EMHighAK)

Case:

A 30-year-old female presents with bilateral lower extremity pain and skin rash. She has had 5 days of cough, shortness of breath, fevers, myalgias, and congestion as well. She has no past medical history.  On exam, she has a temperature of 101F but is normoxic. Her skin exam reveals erythematous papules and macules, bullae, and digital swelling on her feet. You suspect COVID-19 with her symptoms, but what about her rash?

We are in the midst of the COVID-19 pandemic due to SARS-CoV-2. Most patients present with respiratory symptoms, fever, and myalgias, but other systems affected include the cardiovascular, gastrointestinal, neurologic, and dermatologic systems (1,2). Multiple case reports have brought to light skin findings associated with COVID-19.

Why can skin findings occur?

While the angiotensin-converting enzyme 2 (ACE2) receptor is found on lung alveolar epithelial cells, small intestine enterocytes, and vasculature, it is also present in the skin, which can account for the dermatologic symptoms found in patients with COVID-19 (3-8). The virus may be associated with diffuse microvascular vasculitis with complement system activation which may result in rash, but the virus may have a direct effect and cause lymphocyte infiltration, epidermal spongiosis, and papillary dermal edema (5-15). 

Several studies suggest skin findings present several days after other symptoms. These skin findings can occur in up to 20% of patients, though this ranges depending on the study, with one study finding 18 of 88 patients had a rash and another 5 of 103 patients (2,9,12) .

The Rashes

Perhaps the most significant challenge associated with COVID-19 rashes is the myriad of presentations. First, the rash can involve a variety of body regions, most commonly the trunk, followed by the extremities. Lesions typically appear within 3 days and are gone within 8 days. The individual rashes also are associated with wide differentials (9,16).

Table 1. Potential Causes of Each Dermatologic Finding

With that out of the way, let’s discuss some of the rashes…

Maculopapular

Defined by erythematous macules covered with small papules (or larger plaques), maculopapular rashes have been reported in multiple patients (15-20). The rash can be confluent with scaling as well. This rash has been reported in 16% of patients and has a mean duration of 9 days in COVID-19 patients (9,14-22).  The rash may occur on the extremities, trunk, or diffusely. The rash has been described as starting on the trunk and then spreading distally as well (12,15,22-27).

Urticaria

Acute, swollen, read wheals/plaques with pruritis characterize urticaria characterize urticaria. This can affect all age groups and has been reported to occur along all regions of the body, including the trunk, head, and extremities, but no palms or soles (9,10,12,17,25,26,38-31). The rash often migrates. A study of 73 patients with COVID-19 and urticaria found the trunk was most commonly involved, and pruritis occurred in 92% (20). The rash typically lasts for just under 7 days, and urticaria can occur concomitantly with other COVID-19 symptoms. Interestingly, urticaria was associated with increased mortality in one study of patients with COVID-19 (20).

Vesicular

Small, fluid-filled blisters on an erythematous base define vesicular rash. These may occur in approximately 1% of patients, and vesicles are typically scattered, though diffuse involvement can occur (9,16,32). Vesicles most commonly affect the trunk and extremities and last approximately 10 days (11,17,20). One study found vesicles preceded other symptoms and were small and monomorphic with hemorrhagic content, which differs from chicken pox (20).

Petechiae and Purpura

Small subdermal hemorrhages characterize petechiae, while purpura are larger variants. These are less common than other rashes (33). One case report found petechiae occurred in a patient with thrombocytopenia, and another found purpura isolated to flexural areas (33,34). Keep in mind that petechiae and purpura can be associated with vasculitis and/or thrombocytopenia and is a less common rash found in COVID-19.

Chilblains (COVID Toes)

Pernio or perniosis is another term for chilblains, which present as erythematous or violaceous papules and macules, bullae, and/or digital swelling (35). These typically occur due to an abnormal response to a cold environment, with distal vascular constriction leading to pruritic, tender areas on the extremities. This is one of the rashes most commonly associated with COVID-19, with over 100 cases described (17,20,35,36). These lesions most commonly affect the hands or feet and are asymmetric, with approximately 30% associated with pain and 30% with pruritis (20,35). This rash is also more commonly present in younger patients (< 32 years) (32).

Livedo Racemosa

This rash is a violaceous web/net-like skin patterning that appears similar to livedo reticularis, except livedo racemosa appears diffusely (livedo reticularis is typically gravity-dependent) (37). The rash has a mean duration of 9.4 days, and is more common in older patients (mean age 63 years) (17,20,38).  Unfortunately, this rash is associated with more severe disease and a mortality rate of 10% (20).

Distal Ischemia

One of the most severe dermatologic complications is distal ischemia, which can result in necrosis (39). A case series of 7 patients described ischemia with finger/toe cyanosis, bullae, and dry gangrene (39). A second report discussed distal finger ischemia, one with toe ischemia, and one with necrotic purpura (17,40,41). If distal ischemia is present, vascular surgery consultation is recommended.

Back to the Case…

With the patient’s symptoms, you are concerned with COVID-19, and her rash is consistent with chilblains or pernio. She appears otherwise well and improves with symptomatic therapy in the ED, and you discharge her home.

Key Points:

• COVID-19 can result in multiorgan involvement that includes the skin.
• Skin findings may occur due to diffuse microvascular thrombosis or viral exanthem.
• Rashes reported in COVID-19 include maculopapular rash, urticaria, vesicular rash, petechia, purpura, chilblains, livedo racemosa, and distal ischemia.
• These rashes should prompt consideration of COVID-19.
• Severe rashes include livedo racemosa, purpura, and distal ischemia.

References/Further Reading:

1. World Health Organization. Situation Report 110. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ Last accessed: May 9, 2020.
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3. Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol. 2004 Jun;203(2):631-7.
4. Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target. Intensive Care Med. 2020 Apr;46(4):586-590.
5. Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 2020;395:497-506.
6. Zhou F, Yu T, Du R et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-1062.
7. Wang D, Hu B, Hu C et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7. doi: 10.1001/jama.2020.1585. [Epub ahead of print]
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