key: cord-0956573-xajenntw
authors: Sardana, Kabir; Sinha, Surabhi; Yadav, Amlendu; Deepak, Desh; Panesar, Sanjeet; Mathachan, Sinu Rose
title: Paucity of cutaneous manifestations of COVID-19 among inpatients in a referral hospital in India
date: 2022-01-12
journal: JAAD Int
DOI: 10.1016/j.jdin.2022.01.001
sha: f91077a9a508fd8629266bdb4aee292126f8041c
doc_id: 956573
cord_uid: xajenntw

Background Varied cutaneous manifestations have been described in COVID-19, but most studies are based on photographic or app-based observation without directly observed evaluation by dermatologists . Objectives To study the types of cutaneous manifestations of COVID-19 among confirmed inpatients admitted to COVID-19 wards and ICUs. Methods This cross-sectional analysis was conducted at a referral hospital in Delhi, India. Four hundred and forty consecutive RT-PCR confirmed cases diagnosed with moderate or severe COVID-19 disease admitted in COVID-19 wards or ICUs, respectively, were included. A cutaneous finding was considered associated with COVID-19 if it had been described earlier as a consequence of COVID-19 and was observed at or within the first 48 hours of admission (after excluding drugs and comorbidities as causes). Results 270 patients were admitted to COVID wards with moderate COVID-19 disease, while 170 were in ICUs with severe disease. Only 7/270 ward patients (2.59%) and 3/170 ICU patients (1.76%) had cutaneous findings associated with COVID-19. Conclusion Cutaneous findings attributable to COVID-19 are infrequent, and we believe they may have been overestimated/overemphasized in earlier studies. Though coagulopathic findings may be associated with severe COVID-19, an association cannot be established in the absence of case-control studies.

The ages ranged from 3 years to 92 years (mean age in wards (moderate cases) was 46.1 99 years while that in the ICUs (severe cases) was 53.9, [difference in means -7.8 (4.27 -11.32), 100 p<0.001] and males predominated both in the wards and ICUs (64.1% in each group). The average 101 incidence of comorbidities (OR 6.29 (3.81 -10.38), p<0.001) and fatality rate [OR= 4.58 (3.04 -102 6.91), p <0.001] were significantly higher in the ICUs (Table 1) . Diabetes mellitus followed by 103 hypertension were the most common comorbidities in both groups. 104

Dermatologic findings were divided into those that have been described earlier in published 105 literature on COVID-19 and those that were pre-existing or incidental. Maculopapular rash and 106 urticaria were seen in 7/270 (2.6%) ward patients (Figure 1 ), but no vesicles/ pityriasis rosea-like/ 107 chilblain-like lesions were observed. Among ICU patients, coagulopathic skin lesions [retiform 108 purpura/skin mottling (n=2) and acral ischemia (n=1)] were observed in 3/170 (1.76%) patients. A recent paper concurred that while millions of cases of COVID-19 have been seen, the skin 147 findings are neither consistent nor diagnostic or predictive. 18 Thus, at present, it is safe to conclude 148 that it is unlikely that a direct causal association exists unless a large-scale case-control study is 149 able to arrive at predictive rashes that precede COVID-19 or that herald a more severe course. However, the fact that we included only hospitalized patients may have impacted the nature of our 178 findings. Also, ours was a cross-sectional study to estimate the prevalence of cutaneous severe cases was done subsequently as a sub-analysis, and the results thus obtained may be 181 considered as a hypothesis generating study for further comparative studies between moderate and 182 severely ill COVID-19 patients. 183

We would like to reiterate that our study, in conjunction with another large study from India, 184 largely delinks the specificity of skin lesions to COVID-19. 22 The glaring lacunae in the present 185 studies include lack of directly observed patient data, lack of recruitment of consistently positive 186 patients, inconsistent data on examination two days before to two days after diagnosis, detractors 187 like drug exposure & other viral aetiologies, and a lack of case-control data. Also without a well-188 defined diagnostic or prognostic value, focus on cutaneous findings is probably misplaced. This 189 explains why no guideline places credence to any form of cutaneous rash as a prerequisite for 190 performing a RT-PCR, since it would probably lead to unnecessary over-testing. 

Cutaneous manifestations in COVID-19: a first perspective

Classification of the cutaneous manifestations of 197

COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases

The 200 spectrum of COVID-19 associated dermatologic manifestations: an international registry 201 of 716 patients from 31 countires

Skin 203 manifestations in COVID-19 patients, state of the art. A systematic review

A method for 206 estimating the probability of adverse drug reactions

pdf 210 nonhospitalized patients: A case series of 132 patients during the COVID-19 outbreak

Are the cutaneous manifestations during or due to 217

SARS-CoV-2 infection/COVID-19 frequent or not? Revision of possible pathophysiologic 218 mechanisms

Human herpesvirus-6, -7, and Epstein-Barr 220 virus reactivation in pityriasis rosea during COVID-19

The clinics of HHV-6 infection in COVID-19 pandemic: Pityriasis 223 rosea and Kawasaki disease

COVID-19-associated cutaneous manifestations: does human 226 herpesvirus 6 play an aetiological role?

Epidemiologic Analysis of Chilblains Cohorts Before and During the COVID-19

India: an observational study

Cutaneous signs in SARS CoV-2 infection: a plea for 263 more rigorous peer review in the time of COVID-19

Caution in the time of rashes and COVID-19

Not all that glitters is COVID-19: a case 268 series demonstrating the need for histopathology when skin findings accompany SARS-269

270 tuberculosis, chronic kidney disease, malignancy, $ using Mann Whitney's U test