key: cord-340842-s00465sy
authors: Cabrera‐Hernández, R.; Solano‐Solares, E.; Chica‐Guzmán, V.; Fernández‐Guarino, M.; Fernández‐Nieto, D.; Ortega‐Quijano, D.; de‐Andrés‐Martín, A.; Moreno, C.; Carretero‐Barrio, I.; García‐Abellás, P.; González‐de‐Olano, D.; de‐la‐Hoz‐Caballer, B.
title: SARS‐CoV‐2, skin lesions and the need of a multidisciplinary approach
date: 2020-06-13
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16745
sha: 
doc_id: 340842
cord_uid: s00465sy

COVID‐19 is a disease caused by severe acute respiratory syndrome coronavirus 2 of the genus Betacoronavirus (SARS‐CoV‐2). It was first described in Wuhan (China) on December 2019 and has spread to become a pandemic. Its clinical presentation is mainly characterized by cough, fever and dyspnea, although many other symptoms have been described within its presentation pattern. In some cases, it causes an acute respiratory distress that has lead to the death of thousands of people around the world. Furthermore, different types of skin lesions have been described during the infection period of illness.1 In this exceptional situation of global health emergency, physicians are undertaking research work in order to achieve notions on the etiopathogenesis of these skin lesions. The first report of cutaneous manifestations described different forms of skin lesions such as erythematous rash, urticaria and chicken‐pox‐like vesicles.2 Further studies have classified 5 different type of skin lesions, and associated them with patient demographics, timing in relation to symptoms of the disease, severity and prognosis.

This article is protected by copyright. All rights reserved COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 of the genus Betacoronavirus (SARS-CoV-2). It was first described in Wuhan (China) on December 2019 and has spread to become a pandemic. Its clinical presentation is mainly characterized by cough, fever and dyspnea, although many other symptoms have been described within its presentation pattern. In some cases, it causes an acute respiratory distress that has lead to the death of thousands of people around the world. Furthermore, different types of skin lesions have been We present 4 patients with COVID-19, confirmed by positive polymerase chain reaction, who were referred to our service due to the appearance of skin lesions ( Figure 1 ). Two of them developed skin lesions during hospitalization whilst presenting respiratory symptoms and the other two developed skin lesions many days after hospital discharge. Demographic data, description and histology of skin lesions, blood parameters, clinical symptoms and drugs administered are shown in Table 1 . The algorithm of the spanish pharmacovigilance system (ASPS), which evaluates the possible implication of a drug reaction as a cause of the skin lesions,6 was also applied. The ASPS analizes: i) the interval between drug administration and the aparition of skin lesions, ii) the degree of knowledge of the relationship between the drug and the effect described in literature, iii) the evaluation of drug withdrawal, iv) the rechallenge effect, and v) alternative causes. Each item receives and individual subscore, and a total sum ≥ 6 indicates a probable causality.6

This article is protected by copyright. All rights reserved As mentioned above, skin lesions appear to be a sign within patients suffering from COVID-19.

To date, no hypothesis has been proposed to explain if the lesions (including the different types) are attributable to the virus, to drug adverse reactions or to any other clinical condition.

Histopathological study alone cannot conclude an etiology, as it does not distinguish between a posible viral exanthema and a toxicoderma (Figure 1 ). In our series, small enough to draw conclusions, we have found no differences between the multiple types of skin lesions and analytical or clinical features. Even in lesions with apparent vascular involvement, which have been associated with alterations in coagulation,3-5 the analitycal parameters did not differ from those with other types of skin lesions. Regarding drug involvement, since all the patients were exposed to multiple drugs at the same time, the ASPS was not able to differentiate the possibility of drug implication nor the immune mechanisms involved. Thus, further assays with selective (in vitro or in vivo) tests for each drug seem necessary in order to completely rule out drug involvement. In addition, since many patients worldwide are being infected with SARS-Cov-2, and many of them present similar medical history and receive the same treatments, it seems necessary to investigate the existence of an individual predisposition that facilitates the developement of skin lesions. For all these reasons, in order to correctly study the etiology of the skin lesions, a multidisciplinary approach should be carried out.

This article is protected by copyright. All rights reserved 

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

Cutaneous manifestations in COVID-19: a first perspective

Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia

A new vasculitis at the time of COVID-19

Lesiones pernióticas y acrales en España durante el confinamiento por COVID: análisis retrospectivo de 12 casos

Causality assessment in reports on adverse drug reactions. Algorithm of Spanish pharmacovigilance system

The patients in this manuscript have given written informed consent to publication of their case details.

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved