key: cord-0807821-2klditb6
authors: Deo, Neha; Tekin, Aysun; Bansal, Vikas; Koritala, Thoyaja; Mullen, Barbara; Armaignac, Donna L.; Chiotos, Kathleen; Bjornstad, Erica C.; Gharpure, Varsha P.; Bogojevic, Marija; Qamar, Shahraz; Singh, Romil; Sharma, Mayank; Gajic, Ognjen; Kumar, Vishakha; Walkey, Allan; Kashyap, Rahul; Domecq, Juan P.; Alavi, Afsaneh
title: Cutaneous manifestations of hospitalized COVID‐19 patients in the VIRUS COVID‐19 registry
date: 2022-02-19
journal: Int J Dermatol
DOI: 10.1111/ijd.16134
sha: 842c542fcb2be7157d72c550940ccc1c09a4a999
doc_id: 807821
cord_uid: 2klditb6

nan

mating the prevalence as many individuals are asymptomatic and thus untested. 1 Given the global burden and death toll of this pandemic, understanding the presenting signs, disease course, predictors of severity and outcomes, and long-term consequences of COVID-19 is important.

Current literature has documented a vast array of cutaneous manifestations of COVID-19 from maculopapular to vesicular morphology to chilblain-like lesions. 2 We aimed to assess the prevalence of skin findings, characterization of these presentations, clinical outcomes, and treatment regimens using a multinational database of COVID-19-positive hospitalized patients.

We designed a retrospective observational descriptive study of dermatological symptoms from a large international VIRUS:

COVID-19 registry conducted by the Society of Critical Care Medicine (SCCM) Discovery Network. VIRUS is a multinational database that collects and stores patient's data for those who are hospitalized with COVID-19. 3 The VIRUS Registry has enrolled hospitalized patients with laboratory confirmed COVID-19 patients. A laboratory confirmed case is defined as a positive result using a reverse-transcriptase-polymerase chain reaction (RT-PCR) assay.

We created data elements based on smaller studies that were published for patients with dermatologic manifestations of COVID-19. We also utilized the expertise of a dermatologist (A.A.) to determine what data points would be valuable to add.

The data elements for inclusion were selected to capture the types of skin manifestations that develop, patient demographics, dermatologic comorbidities, existing skin allergies, treatments, and their outcomes. These data elements were used to create an Excel document for collection. To collect dermatological symptoms for each patient, we sent an Excel survey to the sites that recorded patients with "rash" in the database. All sites that mentioned "rash" as a symptom were invited to fill out this Excel form. If sites had noted "urticaria," "hives," "itch," or "mottle" in the Research Electronic Data Capture (REDCap) system, they were also asked to fill out this Excel. The charts were reviewed by research members in each site retrospectively. The data abstractors could review these charts and extract the desired variables. A total of 310 individuals out of the 64,580 patients (0.48%) in the VIRUS COVID-19 registry were reported with skin manifestations. In all, 258 were excluded due to incomplete information or lack of response from the study site, and the remaining 52 patients were analyzed (Table 1) .

Most patients were asymptomatic (32, 61.5%); however, some experienced pain/burning (9, 17.3%) or pruritus (13, 25.0%). Skin manifestations related to COVID-19 varied in morphology. Overall, many patients presented with morbilliform/maculopapular eruptions (26, 50%) (Fig. 1 4 These lesions typically follow a benign course. 4, 5 The mortality rate associated with patients with cutaneous presentations is reported as lower than 5%. 6 The pathogenesis of cutaneous lesions is still unclear at this time; however, some theories have been postulated. Complement-mediated activation of lymphocytes can lead to release of proinflammatory cytokines, known as "cytokine storm." 4 These proinflammatory cytokines, such as IL-6 and tumor necrosis factor alpha (TNF-a), can lead to development of microthrombotic events and vasculopathies that result in livedo-reticularis lesions. 5 Additionally, COVID-19 is known to enter cells via the angiotensin-converting enzyme 2 (ACE-2) receptor, which is found in endothelial cells. 5 It is postulated that the virus can gain entry via this route and lead to cutaneous presentations in patients. 5 There are a few limitations to our study. Our data were col- 

COVID-19) Dashboard [Website

Acute acral cutaneous manifestations during the COVID-19 pandemic: a single-centre experience

The viral infection and respiratory illness universal study (VIRUS): an international registry of Coronavirus 2019-related critical illness

Cutaneous manifestations of COVID-19: a systematic review

Cutaneous manifestations in patients with COVID-19: clinical characteristics and possible pathophysiologic mechanisms

skin manifestations in COVID-19 patients: are they indicators for disease severity? A systematic review