Cutaneous manifestations related to coronavirus disease 2019 (COVID-19): A prospective study from China and Italy
Authors: Vincenzo De Giorgi, Sebastiano Recalcati, Ziyi Jia, Wei Chong, Renyu Ding, Yunhua Deng, Federica Scarfi, Federico Venturi, Luciana Trane, Alessia Gori, Flavia Silvestri, Xing-Hua Gao, Torello Lotti
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We report the results of a binational, multicenter, prospective study to assess cutaneous involvement during the course of coronavirus disease 2019 (COVID-19). Between January 1 and March 15, 2020, we investigated the epidemiologic and clinical features of cutaneous manifestations in adult patients with COVID-19. The data were collected prospectively by experienced dermatologists in Wuhan, Hubei province, China, and Lecco, Lombardia region, Italy. Institutional Review Boards approved the study. Four participating hospitals (3 in China, 1 in Italy) enrolled patients diagnosed with COVID-19, according to World Health Organization interim guidance.1World Health Organization Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance.https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspectedDate: 2020Date accessed: March 30, 2020Google Scholar Whenever possible, all new cutaneous findings and pre-existing dermatologic diagnoses were recorded at admission to assess the possible influence of hospital-based treatment and external factors. History and physical examinations were used to categorize all dermatologic conditions as pre-existing vs newly arising. This observational cross-sectional study enrolled 678 patients with polymerase chain reaction-confirmed COVID-19. Patients were classified by disease severity based on Chinese Diagnosis and Treatment Scheme for SARS-CoV-2: 6.0% (41 patients) were considered "critically-ill," 17.5% (118 patients) "severe," 18.7% (127 patients) "common," and 57.8% (392 patients) "mild." In this cohort, 53 patients (7.8%) had new dermatologic conditions that were detected at admission or during hospitalization. This subgroup was a mean age of 55.9 years (range, 28-69 years), and 60% were men (Table I). Of the dermatologic conditions, 44% were present on the day of the COVID-19 diagnosis, roughly at the onset of the typical flu-like symptoms. The remaining 56% of dermatoses were observed at a mean of 11.7 days (range, 2-23 days after hospitalization).Table IMain epidemiologic and clinical characteristics of the study populationVariablesPatients∗Patient data are presented as number (%) or mean (range).TotalPatients with COVID-19 (pharyngeal swab-positive)678 Italian patients92 Chinese patients586Degree of disease severity†Degree of disease severity: For the mild type: slight clinical symptoms with no pneumonia presentation in imaging. For the common type: manifestations such as fever or respiratory presentation with pneumonia by radiography, or both. For the severe type (meeting any of the following conditions): (1) dyspnea, respiration rate 30 times/min; (2) finger oxygen saturation under resting 93%; (3) arterial partial pressure of arterial oxygen/fraction of inspired oxygen 300 mm Hg (1 mm Hg = 0.133 kPa). For the critical type (meeting any of the following conditions): (1) respiratory failure requiring mechanical ventilation; (2) shock; (3) combined with other organ failures requiring an intensive care unit. Critical types41 (6) Severe types118 (17.5) Common types127 (18.7) Mild types392 (57.8)Patients with COVID19 with skin manifestations53 (7.8) Male32 (60) Female21 (40)Age, y55.9 (28-69) Chinese patients53.2 (28-65) Italian patients58.6 (35-69)Inflammatory skin manifestations related to COVID-1953 Erythematous rash37 (70) Diffuse urticaria14 (26) Varicelliform rash with vesiculation2 (4)Vascular skin manifestations in intensive care patients Diffuse petechiae, purpura, and acroischemia13Onset of inflammatory skin manifestations related to COVID-1953 Before hospitalization23 (44) After hospitalization30 (56)Duration of inflammatory skin manifestations, d3 (2-5)COVID-19, Coronavirus disease 2019.∗ Patient data are presented as number (%) or mean (range).† Degree of disease severity: For the mild type: slight clinical symptoms with no pneumonia presentation in imaging. For the common type: manifestations such as fever or respiratory presentation with pneumonia by radiography, or both. For the severe type (meeting any of the following conditions): (1) dyspnea, respiration rate 30 times/min; (2) finger oxygen saturation under resting 93%; (3) arterial partial pressure of arterial oxygen/fraction of inspired oxygen 300 mm Hg (1 mm Hg = 0.133 kPa). For the critical type (meeting any of the following conditions): (1) respiratory failure requiring mechanical ventilation; (2) shock; (3) combined with other organ failures requiring an intensive care unit. Open table in a new tab COVID-19, Coronavirus disease 2019. Of the 53 patients with new inflammatory skin findings, the most common finding was erythematous rash (70%), seen over a wide spectrum of clinical appearances (macular, papular, maculopapular, and erythema multiforme-like eruptions), followed by diffuse urticaria (26%). Two patients (4%) had scattered vesicular, varicelliform eruptions2Marzano A.V. Genovese G. Fabbrocini G. et al.Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients.J Am Acad Dermatol. 2020; 83: 280-285Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar; in both, we ruled out herpes simplex virus and varicella zoster virus clinically and by performing polymerase chain reaction. Most patients who presented with an erythematous rash had mild itch. There was no correlation between the presence of rash and fever. Involved sites were primarily the trunk and upper limbs, but the head and face were largely spared. In this group, younger patients seem to display more intense and disseminated cutaneous manifestations, including darker red, larger wheal-like and purpuric lesions. All exanthems were short-lived and resolved spontaneously without specific dermatologic treatment after mean of 3 days (range, 2-5 days). The dermatologic manifestations could not be correlated to COVID-19 severity. Diffuse petechiae, gravity-dependent, and multiple, generalized palpable purpura, and acroischemia (primarily finger/toe cyanosis, but neither skin bulla nor dry gangrene) were seen in more severe cases. These manifestations were associated with clotting disorders, reflected in increased prothrombin time and fibrinogen and D-dimer levels, which are seen in intensive care patients.3Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 6736: 1-10Google Scholar, 4Chen N. Zhou M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (14520) Google Scholar, 5Fernandez-Nieto D. Jimenez-Cauhe J. Suarez-Valle A. et al.Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak.J Am Acad Dermatol. 2020; 83: e61-e63Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar In conclusion, some patients with COVID-19 present with inflammatory cutaneous findings: 7.8% in our cohort of hospitalized adults. These skin findings are generally mild and self-limiting and do not correlate with overall prognosis. They generally resolve promptly without specific therapy.