to be the underlying pathophysiology in the development of severe disease.12
Diagnosis of COVID-19 relies on physical examination, oximetry screening, chest X-rays, and CT scans but laboratory tests provide the definitive diagnosis. RT–PCR-based viral RNA detection is sensitive and can rapidly and effectively confirm early SARS-CoV2 infection.13 Virus-specific antibody testing can also be helpful for the diagnosis of suspected patients with negative RT–PCR results. Chest X-rays or CT scans can also aid diagnosis: pulmonary radiologic indicators of COVID-19 are changes in the outer zone of the lungs, multiple ground- glass opacity, pulmonary consolidation, and seldomly pleural effusion.14
Cutaneous manifestations of COVID-19 such as urticaria, erythematous, petechial rashes and varicella-like cysts have been already reported in a plethora of recent publications.15-19 In one study up to 20% of COVID-19 patients hospitalized in intensive care were shown to have skin symptoms, though their association with the virus was not verified;19 thus far, the estimated prevalence of such symptoms ranges from 0.2%–20.4%.4,20-23 We here report the seven main types of cutaneous manifestations from forty-five patients in three clinical sites in North and South America. The classification can aid dermatologists and other medical specialties to accurately recognize cutaneous symptoms of COVID-19 in a timely manner when screening patients in person or through telemedicine on these manifestations.7,24
Diagnosis of COVID-19 relies on physical examination, oximetry screening, chest X-rays, and CT scans but laboratory tests provide the definitive diagnosis. RT–PCR-based viral RNA detection is sensitive and can rapidly and effectively confirm early SARS-CoV2 infection.13 Virus-specific antibody testing can also be helpful for the diagnosis of suspected patients with negative RT–PCR results. Chest X-rays or CT scans can also aid diagnosis: pulmonary radiologic indicators of COVID-19 are changes in the outer zone of the lungs, multiple ground- glass opacity, pulmonary consolidation, and seldomly pleural effusion.14
Cutaneous manifestations of COVID-19 such as urticaria, erythematous, petechial rashes and varicella-like cysts have been already reported in a plethora of recent publications.15-19 In one study up to 20% of COVID-19 patients hospitalized in intensive care were shown to have skin symptoms, though their association with the virus was not verified;19 thus far, the estimated prevalence of such symptoms ranges from 0.2%–20.4%.4,20-23 We here report the seven main types of cutaneous manifestations from forty-five patients in three clinical sites in North and South America. The classification can aid dermatologists and other medical specialties to accurately recognize cutaneous symptoms of COVID-19 in a timely manner when screening patients in person or through telemedicine on these manifestations.7,24
METHODS
Between 26 March and 16 June 2020, we investigated the epidemiologic and clinical features of cutaneous manifestations in forty-five patients that tested positive for COVID-19.The data were collected prospectively by experienced dermatologists from two dermatologic clinical in Sao Paolo, Brazil (Almeida Dermatology and Arruda Dermatology) and one from New York City, NY, USA (Sadick Dermatology). Patient demographics, dermatologic symptoms, COVID-19 history and symptoms, and past medical history was obtained from all patients. Skin biopsies, CT scans, and blood tests were conducted in patients as deemed appropriate. Since the intent of the prospective study was to obtain information for educational purposes and healthcare delivery, no Institutional Board Review approval (IRB) was required as it was determined to not meet the definition of Human Subjects Research. Written informed consent was obtained from all patients or their caregivers.
RESULTS
Forty-five patients with cutaneous manifestations who had not started treatment with any new drug in the 15 days preceding lesion onset were referred to the clinic.The average patient age was 37.2±19 (range, 1–68), 55.6% were male, and the majority had comorbidities (atopic dermatitis n=34; cardiac/circulatory conditions n=5, diabetes n=5, asthma n=3, and alopecia n=11).
All patients had COVID-19 infection confirmed by RT-PCR and antibody-test. Aside from cutaneous lesions, the most common symptoms amongst patients were fever, anosmia, headache, and diarrhea; 44% (n=20) had no symptoms. Average time until resolution of symptoms was 9.2 days (Supplemental Table 1).
Seven types of cutaneous manifestations were observed: exanthematous/molbilliform, urticaria, maculopapular/pustular, petechiae, livedo reticularis, chilblains, and telogen effluvium. These were not mutually exclusive, as more than one type could present within the same patient.
Exanthematous/molbilliform: Five patients (11%) presented exanthematous/molbilliform rash, characterized by monomorphic papulo-vesicular lesions (Figure 1A). These most commonly were found on the trunk, face, hands, and feet. Pruritis was pres- ent in three patients and the symptoms appeared 2–3 days prior to the appearance of other systemic symptoms such as fever. Histological analysis showed dilation of the superficial dermal plexus and a mild lymphocytic perivascular infiltrate without vasculitis (Figure 1B).
All patients had COVID-19 infection confirmed by RT-PCR and antibody-test. Aside from cutaneous lesions, the most common symptoms amongst patients were fever, anosmia, headache, and diarrhea; 44% (n=20) had no symptoms. Average time until resolution of symptoms was 9.2 days (Supplemental Table 1).
Seven types of cutaneous manifestations were observed: exanthematous/molbilliform, urticaria, maculopapular/pustular, petechiae, livedo reticularis, chilblains, and telogen effluvium. These were not mutually exclusive, as more than one type could present within the same patient.
Exanthematous/molbilliform: Five patients (11%) presented exanthematous/molbilliform rash, characterized by monomorphic papulo-vesicular lesions (Figure 1A). These most commonly were found on the trunk, face, hands, and feet. Pruritis was pres- ent in three patients and the symptoms appeared 2–3 days prior to the appearance of other systemic symptoms such as fever. Histological analysis showed dilation of the superficial dermal plexus and a mild lymphocytic perivascular infiltrate without vasculitis (Figure 1B).
Urticaria/Erythema: Nine patients (20%) presented urticaria. Generalized and partially confluent wheals surrounded by mild erythema were present in the face, trunk, and extremities (Figure 2A). Moderate to severe pruritus often coexisted. Urticaria was either the only symptom or preceded the onset of systemic symptoms by 24–48 hours. Histological analysis revealed an interface dermatitis with lymphocytic vasculitis of the superficial plexus, characterized by foci of red cells extravasation (Figure 2B).
