key: cord-340474-hbcu72cm
authors: Kaushik, Akanksha; Parsad, Davinder; Kumaran, Muthu Sendhil
title: Urticaria in the times of COVID‐19
date: 2020-06-12
journal: Dermatol Ther
DOI: 10.1111/dth.13817
sha: 
doc_id: 340474
cord_uid: hbcu72cm

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morbidity and severe economic disruptions in recent times.

Of late, there has been a growing interest regarding the dermatological manifestations in COVID-19. In an early retrospective study among 140 patients Zhang et al 1 reported 11.4% patients to have drug hypersensitivity and 1.4% to have urticaria. In a report from Italy, 18/88 (20.5%) patients had dermatological manifestations, with 3 patients reporting widespread urticaria. 2 As per one review, 88/256 (34.3%) patients across 16 studies demonstrated skin manifestations, mostly as erythematous maculopapular rash, urticaria or vesicular rash. 3 On closer look, we find urticaria to be a commonly reported finding among COVID-19 patients.

In one of the large prospective studies involving 375 COVID 19 cases, urticaria was present in 19% cases, with mean duration of urticaria being 6.8 days. 4 While there was a report of one COVID-19 patient presenting with urticaria and dry cough without any fever, 5 the timing of appearance of urticaria was variable, with lesions appearing before, with, as well as >48 hours after onset of fever. [6] [7] [8] [9] In most cases, diagnosis of urticaria was made clinically and oral 2 nd generation antihistamines were prescribed with satisfactory results. [6] [7] [8] [9] Although skin manifestations did not correlate with disease severity in most case reports, 2,6 the prospective This article is protected by copyright. All rights reserved. study from Spain suggested that presence of urticaria and maculopapular lesions were associated with more severe COVID 19 illness and a higher (2%) mortality. . 4 Pathophysiology of urticaria in COVID-19 infection is hypothesised to be multifactorial. While drug-induced urticaria may be an obvious explanation, urticaria preceded drug therapy or showed spontaneous remission despite continuation of therapy for COVID-19, 6 With an ever-rising number of patients, it is too early to determine a precise prevalence of urticaria in COVID-19 and full understanding of pathophysiologic mechanisms may also take time. With an eye on the reported literature, we make a few suggestions regarding urticaria in This article is protected by copyright. All rights reserved. (Table 1) . From management perspective, oral 2 nd generation antihistamines seem to be an initial prudent choice. Omalizumab can be used in refractory patients, with the first two doses being given in a hospital setting as per a recent guidance summary. 11 We reiterate that data so far is relatively sparse and at times, incomparable. As more studies are performed, medical science would be in a better position to elucidate the conundrum of urticaria in COVID-19.

Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan

Cutaneous manifestations in COVID-19: a first perspective

Cutaneous manifestations of the Coronavirus Disease 2019 (COVID-19): A brief review

Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases

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SARS-Coronavirus-2 and acute urticaria

Acute urticaria with pyrexia as the first manifestations of a COVID-19 infection

Urticaria in a patient with COVID-19: Therapeutic and diagnostic difficulties

Comment on: Cutaneous manifestations in COVID-19: a first perspective. Safety concerns of clinical images and skin biopsies

Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases

The Role of Cytokines including Interleukin-6 in COVID-19 induced Pneumonia and Macrophage Activation Syndrome-Like Disease

This article is protected by copyright. All rights reserved.

Service. Accessed June 7, 2020. https://www.sps.nhs.uk/articles/summary-of-covid-19medicines-guidance-skin-disorders/ This article is protected by copyright. All rights reserved.2. In patients with refractory urticaria and/or atypical morphology, the decision to perform skin biopsy and histopathological examination can be individualised.3. For symptomatic management of urticaria, standard doses of potent, second-generation, non-sedating H1 antihistamines (e.g. fexofenadine/ levocetrizine) in twice-daily dosing can be used. In non-responders, the dose can be increased upto four-fold the recommended dose (EAACI guidelines).