key: cord-0740906-expmpor9
authors: Tan, Cyrene C.; Dofitas, Belen L.; Frez, Ma. Lorna F.; Yap, Celina Daia D.; Uy, Jeanie Karen K.; Ciriaco-Tan, Cynthia P.
title: CUTANEOUS MANIFESTATIONS OF COVID-19 IN A TERTIARY COVID REFERRAL HOSPITAL IN THE PHILIPPINES
date: 2022-02-02
journal: JAAD Int
DOI: 10.1016/j.jdin.2022.01.007
sha: 306d19035bd9f786fa6529bba81dae0829920ea3
doc_id: 740906
cord_uid: expmpor9

Background Reports on COVID-19 skin manifestations and associated clinical outcomes are limited. Like viral diseases, cutaneous findings may be present and can help in confirmation and prognostication among those suspected or diagnosed with COVID-19. Objective To determine COVID-19 cutaneous manifestations and their association with disease severity and course. Methods This study was conducted in a designated COVID-referral hospital from January 1 to March 31, 2021. Skin manifestations recorded from January 1 to February 17 were retrospectively gathered. Reports from February 18 to March 31 were prospectively collected using a dermatologic checklist which was incorporated in all official medical records. Results A total of 507 confirmed COVID-19 patients were included. COVID-19 skin signs were detected in 39 patients (7.7%). Morbilliform lesions were most common. Skin signs were significantly associated with severe or critical cases (OR 3.4; 95% CI 1.3 to 8.7) and mortality (RR 2.9; 95% CI 2.0 to 4.2). Limitation Underestimation of prevalence of COVID-19 skin signs due to exclusion of outpatient and discharged patients and the subjective assessment in the retrospective part. Conclusion Cutaneous signs were significantly associated with severe/critical COVID-19 as well as death among 507 hospitalized patients in a Philippine COVID referral hospital.

informed consent from the patient or a legally-authorized representative (for incapacitated 134 patients) either through face-to-face or phone call. Teledermatology followed a standard 135 format of confidentiality and privacy protocols on photography of skin lesions and patient 136 information. In-person dermatological assessment and management were executed when 137 deemed necessary and subsequently documented in the electronic medical records. 138

Data from the two parts underwent independent analyses. 139

Outcomes of interest for both parts were age, COVID disease severity at the time of 140 appearance of skin signs and symptoms, cutaneous manifestations (morphology) and clinical 141

Categorical variables (i.e. age, disease severity, clinical outcome) were reported as numbers 143 and percentages of patients. 144

Pearson's chi squared test or Fisher's exact test were used to determine associations between 145 skin signs and age, disease severity, clinical outcome. The latter was used when more than 20% 146 of the cells had an expected value of less than or equal to five (5). Furthermore, each cutaneous 147 morphology was statistically analyzed for association with disease severity and clinical 148 outcome. 149 Of the 152 records reviewed, 96.30% were adults and there was an almost equal proportion 164 of mild/moderate cases and severe/critical cases. Only 27 patients (17.8%) presented with skin 165 lesions, of which 13 (8.6%) showed the reported COVID-19 skin signs. The morbilliform rash 166 was the most common sign (Table II) . There were 355 patients included and majority (97.46%) were adults. Mean age was 52.9 170 years old (SD 17.6). Forty-three patients (12.1%) presented with skin lesions, and only 26 171 patients (7.3%) presented with the reported COVID-19 skin signs. Majority were severe/critical 172 (59.3%). The morbilliform morphology was still most common followed by livedo reticularis. 173

Urticarial, petechial, vesicular and pernio lesions were also documented (Table II) . Due to the relatively low number of cases with COVID skin signs, the association between 198 each cutaneous lesion morphology and disease severity or outcomes was not detected. 199

There were six inpatient referrals for in-person dermatologic assessment and management 202 for COVID-related skin signs. Five patients had morbilliform lesions and one patient had 203 discrete dusky nodules on the abdomen and a perianal plaque (Table V) . This study conducted a chart review and prospectively collected data over three months 219 from 507 COVID-19 admitted patients in a tertiary medical facility. Significant associations 220

with the presence of skin signs and severe/critical cases and those with poor clinical outcomes 221 (i.e., death) among COVID-19 patients were noted. COVID-19 varies between 1.8 and 20.4%. 20 In this present study, a total of 39 out of 507 cases 234 (7.7%) showed cutaneous manifestations among admitted COVID-19 patients, a percentage 235 that falls within the above-mentioned international range. 236 COVID-19 has been shown to affect any age, with adult predominance, as seen in this 237 study with more than 95% of cases older than 18 years, and a mean of around 50 years. 238

Currently, there is scarce data on the association of skin manifestations of COVID-19 with age. 239

This study showed no association of cutaneous signs and symptoms with age. were being reported. By January 2020, the novel coronavirus, initially called 2019-nCoV, was 518 identified and the disease was subsequently renamed to Coronavirus disease 19 (COVID-19) . 519

By the end of January, cases were already reported outside China. 1, 2, 6, 7, 10 In March 2020, 520 COVID-19 was declared a global pandemic. 521

In the Philippines, new cases were noted between January to March 2020. In response, 522 the Department of Health designated institutions as official COVID referral hospitals. By 523

March 30, 2020, the University of the Philippines -Philippine General Hospital (UP-PGH) 524 began its COVID operations. Since RT-PCR testing was still limited due to lack of kits and 525 facilities, diagnosis was through symptomatology, probable exposure history, other 526 diagnostics, and imaging. 527

Although complaints were mainly respiratory and gastrointestinal, there were few 528 reports on COVID-19 dermatologic manifestations. Viral infections, like COVID-19, may 529 present with skin signs that can help confirm diagnosis. Dermatologic signs and symptoms may 530

give a unique perspective and correlation to disease course and prognostication. 531

During protocol development, there was still scarcity of evidence on COVID-19 532 cutaneous manifestations (Table I) . Literature search was done through the PubMed database 533 using the following search terms: "Coronavirus 19", "COVID-19", "SARS Cov-2", "skin", 534 "cutaneous" and "dermatologic" generated a variety of dermatologic manifestations. 535 536 This study aims to document the cutaneous manifestations among COVID-19 patients 538 and determine associations between skin manifestations and disease severity and clinical 539

This study was conducted in a COVID Referral Hospital in Metro Manila, the 542 University of the Philippines -Philippine General Hospital. There were two parts: a preliminary 543 retrospective cross-sectional study of all COVID-19 in-patient records from January 1 to 544

February 17, 2021, and a subsequent prospective cohort study of admitted COVID-19 patients 545

between February 18 to March 31, 2021. The study protocol was approved by the institution's 546

Research Ethics Board. 547 COVID-19 cases, of any sex and age group, and disease severity types were included 548 in the retrospective study. All patient records were retrieved using standard data collection 549 forms with strict selection criteria. Records which did not meet at least 30% of the criteria were 550 excluded. Information extracted were demographics, clinical data i.e., disease severity (mild/ 551 moderate/ severe/ critical), comorbidities and clinical outcome (good/improved/discharged or 552 poor/deceased), and all dermatologic signs and symptoms. Case definitions were adapted from 553 the Philippine Society for Microbiology and Infectious Diseases Interim Guidance. 21 554

The prospective part included all admitted COVID-19 confirmed patients and excluded 555 probable and suspect cases. A dermatologic checklist was developed based on current literature 556 of the COVID-19 cutaneous presentations (Table 1) Pearson's chi squared test or Fisher's exact test were used to determine associations between 581 skin signs and age, disease severity, clinical outcome. The latter was used when more than 20% 582 of the cells had an expected value of less than or equal to five (5). Furthermore, each cutaneous 583 morphology was statistically analyzed for association with disease severity and clinical 584 outcome. 585 (Table II) . There were 355 patients included and majority (97.46%) were adults. Mean age was 52.9 606 years old (SD 17.6). Forty-three patients (12.1%) presented with skin lesions, and only 26 607 patients (7.3%) presented with the reported COVID-19 skin signs. Majority were severe/critical 608 (59.3%). The morbilliform morphology was still most common followed by livedo reticularis. 609

Urticarial, petechial, vesicular and pernio lesions were also documented (Table II) . Due to the relatively low number of cases with COVID skin signs, the association between 634 each cutaneous lesion morphology and disease severity or outcomes was not detected. 635 636

There were six inpatient referrals for in-person dermatologic assessment and management 638 for COVID-related skin signs. Five patients had morbilliform lesions and one patient had 639 discrete dusky nodules on the abdomen and a perianal plaque (Table V) . 

Balmores for dermatopathology discussions, Dr. Zimri C. Tan for 759 writing suggestions and feedback and

Villaverde for contributions to patient management and infographic design

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Interim guidance on 834 the clinical management of adult patients with suspected or confirmed COVID-19 835 infection, Version 3.1 as of

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081X

Associated with COVID-19: Current Knowledge and Future Perspectives

We thank the following for their great assistance and invaluable work: Dr. Zuriel Alkian C. 757Tan for data acquisition and organization, Dr. Al Joseph R. Molina for statistical advice and 758

different types of skin manifestations, some presenting at disease onset while others after 668 hospitalization. 5 Kaya et al. reviewed 57 articles and reported that cutaneous involvement in 669 COVID-19 varies between 1.8 and 20.4%. 20 In this present study, a total of 39 out of 507 cases 670 (7.7%) showed cutaneous manifestations among admitted COVID-19 patients, a percentage 671 that falls within the above-mentioned international range. 672 COVID-19 has been shown to affect any age, with adult predominance, as seen in this 673 study with more than 95% of cases older than 18 years, and a mean of around 50 years. 674Currently, there is scarce data on the association of skin manifestations of COVID-19 with age. 675This study showed no association of cutaneous signs and symptoms with age.