Since the coronavirus pandemic, reports of skin lesions in patients with COVID-19 have been appearing with increasing frequency. The first publication appeared in the New England Journal of Medicine, reporting two Chinese patients who developed a rash whilst infected with coronavirus [1]. Since then, further reports of skin manifestations in infected patients have appeared [2-5].
Of most interest to podiatrists perhaps has been the reported lesions arising on the feet of patients resembling chilblains, noted by Spanish colleagues. Consequently, in response the College of Podiatry in the UK sent out a member update statement on this phenomenon on 24 April 2020 [6]. This included a link to the article recently published in Journal of the American Podiatric Medical Association by Dr Rami Basatneh & Tracey Vlahovic [7]. What is clear at this time is that despite the number of reports appearing in the journals, on the news and in social media, it is difficult at this stage to draw any hard conclusions as to how common skin lesions are in COVID-19 patients, what they are and how they may arise. Case reports have been light on description, lacking histology and often it is not clear if the reported patients actually had confirmed coronavirus.
A letter has recently been published in the Journal of the American Academy of Dermatology (JAAD) which reviews the evidence to date has somewhat similar conclusions to those made above [8]. As they rightly point out, at this stage few COVID-19 patients have undergone dermatological consultation and investigation to begin to properly examine the issue. In the paper they have listed the types of skin lesions that have been reported to date. These include:
1. Morbilliform rash – a measles like rash.
2. Petechiae – bleeding which leads to non-blanchable, purple lesions.
3. Urticaria – skin wheals.
4. Varicella (chicken pox) like vesicles.
5. Lesions resembling vasculopathy – peripheral cyanosis with blister, livedo reticularis, chilblain-like lesions on the digits and dry gangrene.
They go on to suggest that the presenting rash in a COVID-19 positive patient may be due to one of three reasons: direct effect of the viral infection itself, lesions arising from the systemic effects of the infection such as vasculitis and thrombosis, or as a result of the medication patients maybe taking at the time of their infection. Many infected patients maybe prescribed various medications for the infection or other disorders which are known to cause rashes. For example, hydroxychloroquine, azithromycin and lopinavir are all known to cause morbilliform rashes – observed in COVID-19 positive patients.
For the moment, this is all that we know but as things progress and more detailed assessment of these patients is available with histology and detailed blood chemistry and immunology, the picture may become clearer.
References
1. Guan, W.-j., et al., Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, 2020.
2. Fernandez-Nieto, D., et al., Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak. Journal of the American Academy of Dermatology, 2020: p. early view.
3. Marzano, A.V., et al., Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients. Journal of the American Academy of Dermatology, 2020: p. early view.
4. Manalo, I.F., et al., A Dermatologic Manifestation of COVID-19: Transient Livedo Reticularis. Journal of the American Academy of Dermatology, 2020.
5. Joob, B. and V. Wiwanitkit, COVID-19 can present with a rash and be mistaken for Dengue. Journal of the American Academy of Dermatology, 2020: p. S0190-9622(20)30454-0.
6. College of Podiatry, Update on reports of skin-related symptoms in COVID - 19 [e-mail]. 2020, College of Podiatry: London.
7. Basatneh, R. and T.C. Vlahovic, Addressing the Question of Dermatologic Manifestations of SARS-CoV-2 Infection in the Lower Extremities: A Closer Look at the Available Data and its Implications. Journal of the American Podiatric Medical Association, 2020.
8. Suchonwanit, P., K. Leerunyakul, and C. Kositkuljorn, Cutaneous manifestations in COVID-19: Lessons learned from current evidence. Journal of the American Academy of Dermatology, 2020.