key: cord-0841778-y25ujcfk
authors: Suchonwanit, Poonkiat; Leerunyakul, Kanchana; Kositkuljorn, Chaninan
title: Cutaneous manifestations in COVID-19: Lessons learned from current evidence
date: 2020-04-24
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.04.094
sha: c41198dfe1d306e6500728c94b8461403f6222b3
doc_id: 841778
cord_uid: y25ujcfk

nan

The ongoing pandemic of coronavirus disease 2019 (COVID-19) is a significant global concern.

As of April 19, 2020, a total of 2,241,359 accumulated cases and 152,551 deaths have been reported worldwide. 1 The clinical features of COVID-19 have been described in several articles.

The disease typically presents with symptoms resembling other viral respiratory infections, most commonly with fever and dry cough. Severe patients may later develop acute respiratory distress syndrome that could progress to multiple organ failure with a relatively high mortality rate. 2 Additionally, the disease is associated with leukopenia, thrombocytopenia, and elevated D-dimer levels that increase the risk of venous thromboembolism. 3 Emerging evidence suggests that the uncontrolled release of proinflammatory cytokines resulting in cytokine storm syndrome plays an immunopathogenic role in disease progression and the development of severe disease. 4 Cutaneous manifestations are considered an infrequent presentation of COVID-19, being rarely described in the literature. They are probably underrecognized due to a lack of dermatology consultations in this group of patients. The first evidence of skin manifestations was reported in 2 patients with severe respiratory disease, in a study of 1,099 cases in China. However, neither characteristics, nor progression of the lesions were documented. 2 Since then, subsequent case reports and case series have described COVID-19-associated skin lesions in confirmed COVID-19 cases, including clinical features that indicate viral exanthems (ie, morbilliform rash, petechial rash co-existing with thrombocytopenia, erythematous-to-purpuric coalescing macules, widespread urticaria, and varicella-like vesicles) and vasculopathy-related skin manifestations (ie, peripheral cyanosis with bullae and dry gangrene, transient unilateral livedo reticularis, and red papules on fingers resembling chilblains). Other non-laboratory-confirmed COVID-19 cases showed urticaria and painful erythematous-to-violaceous patches evolving into tense vesicles or dark crusts. All cases reported so far are summarized in Table 1 .

According to preexisting data, we can speculate that cutaneous manifestations in COVID-19 may present in 2 major groups regarding their pathomechanisms: (1) clinical features similar to viral exanthems, an immune response to viral nucleotides; and (2) cutaneous eruptions secondary to systemic consequences caused by COVID-19, especially vasculitis and thrombotic vasculopathy. Apart from the above-mentioned, patients with COVID-19 are more likely to increase the risk of adverse drug reactions and interactions of their treatment, causing secondary cutaneous reactions at any point during the course of the disease. Therefore, it is essential to identify clues that support either viral cause or drug eruption. Table 2 

World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report -90

Clinical Characteristics of Coronavirus Disease

Coronavirus disease 2019 (COVID-19) and cardiovascular disease

COVID-19: consider cytokine storm syndromes and immunosuppression

Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A Review