Presentation and Management of Cutaneous Manifestations of COVID-19

January 2021 | Volume 20 | Issue 1 | Original Article | 76 | Copyright © January 2021

Published online December 24, 2020

Guilerme Almeida MDa, Suleima Arruda MDb, Elaine Marques MDa, Nichola Michalany MDc, Neil Sadick MDd

aHospital Sirio libanês, São Paulo, Brazil; Olsen de Almeida Dermatology, São Paulo, Brazil
bArruda Dermatology, Sao Paulo, Brazil; Sadick Research Group, New York, NY
cPathologist at Universidade Federal de São Paulo, Sao Paulo, Brazil
dDepratment of Dermatology at Weill Cornell Medical College; Sadick Dermatology; NewYork,NY

Introduction: The spread of the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has instigated a fervent race of the medical community to identify its manifestations, the patients at risk, and optimal disease management. While the COVID-19 illness is largely associated with respiratory consequences, there is increased reporting of other organ-specific disease sequelae that include the skin.
Objective: To identify, describe, and classify the main skin manifestations of COVID-19 and associated protocols for management.
Methods: Forty-five patients from three clinical centers in North and South America with positive COVID-19 PCR and/or serology presenting cutaneous manifestations were included in this retrospective chart review. Medical history, biopsies, dermoscopy, laboratory findings, clinical photography, and disease management were documented.
Results: Seven main types of cutaneous manifestations were identified: exanthema/molbilliform, urticaria, papular/pustular/vesicular, petechiae/purpura, livedo reticularis, chilblains, and alopecia. Histopathogical analysis from skin biopsies and/or dermoscopy highlighted an inflammatory or vascular pathophysiology depending on the type of manifestation. While the first three types of COVID-19 skin manifestations preceded or coincided with other symptoms such as anosmia, fever, chills, chilblains, and livedo were found in later disease stages. All cases had a positive resolution with appropriate treatment.
Conclusions: Cutaneous symptoms are part of the COVID-19 disease spectrum. Early identification, diagnosis, and management through a multidisciplinary approach can facilitate safe disease resolution for patients.

J Drugs Dermatol. 20(1):76-83. doi:10.36849/JDD.2021.5676


The novel coronavirus disease (COVID-19) emerged in late 2019 in China, spread globally, and was declared a pandemic by the World Health Organization (WHO) in March 2020. It is a zoonotic illness originating in bats and caused by a single-stranded RNA virus known as 2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 is primarily transmitted between people through respiratory droplets and contact routes, which is why social distancing and personal protective equipment is recommended to decrease the infectivity.1 The mean incubation period is 5.2 days and 95% of patients develop symptoms up to 12.5 days after exposure.2,3

Patients infected with COVID-19 can present fever, fatigue, dry cough, breathing difficulties, myalgias, sore throat, anosmia, neurologic and gastrointestinal disturbances, such as diarrhea, or be completely asymptomatic.4-7 The most severe cases develop dyspnea, with or without hypoxemia, a week after the onset of symptoms and deteriorate to acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation, septic shock, and metabolic acidosis. Patients most susceptible to negative outcomes are the elderly and those with comorbidities such as hypertension, obesity, diabetes, and renal failure.8 There have been some reports that increased COVID-19 viral load, viral dissemination, and severity of lung involvement is androgen-dependent rendering males more vulnerable to the disease but this has yet to be proven.9,10

Laboratory findings of COVID-19 infection include leukopenia, thrombocytopenia, elevated interleukin-6 (IL-6) levels, and increased D-dimer levels that increase the risk of venous thromboembolism.11 Aberrant release of proinflammatory cytokines resulting in cytokine storm syndrome is suggested