Comment on 'Cutaneous manifestations in COVID-19: a first perspective' by Recalcati S.

Dear Editor,

Since the coronavirus disease 2019 (COVID‐19) outbreak was first reported in the Chinese city of Wuhan on 31 December 2019, it has stricken more than 1 000 000 persons worldwide, of whom over 50 000 have died. Having been infected by severe acute respiratory syndrome coronavirus 2 (SARS‐COV‐2), patients with COVID‐19 mainly present with fever and respiratory symptoms. Isolated sudden onset anosmia has also frequently been reported. Less frequently, rhinorrhea, diarrhoea and dysgeusia may be associated. While only a few reports have evoked cutaneous manifestations, we read with interest an initial study on the topic entitled ‘Cutaneous manifestations in COVID‐19: a first perspective’ by Recalcati S. This Italian study including 88 patients with COVID‐19 reported 20.4% of cutaneous manifestations such as erythematous rash, widespread urticaria and chickenpox‐like vesicles. In France, while social networking has facilitated communication and exchanges between French doctors, we have not noticed as many skin manifestations.

We have constructed a prospective study to analyse the incidence and the types of cutaneous manifestations associated with COVID‐19 infections in France. We included patients confirmed as infected by COVID‐19 by nasopharyngeal PCR and recorded (i) the presence of cutaneous manifestations, whether they appeared during prodromal, illness or decline periods, (ii) the type and location of the lesions and (iii) the symptoms associated with the lesions (itching, burning).

One hundred and three patients were included in the study between 15 March 2020 and 2 April 2020. There were 71 women and 32 men with a mean age of 47 years (range 20–88). Among them, 76 were treated at home, 23 were admitted in conventional hospitalization and four were admitted to intensive care. None of these patients died. Only 5 (4.9%) presented with cutaneous manifestations. There were instances of erythematous rash (n = 2) and urticaria (n = 2), mainly located on the face and the upper body. We also observed an oral herpes simplex virus type 1 (HSV‐1) reactivation in an intubated patient in intensive care. Four of these skin lesions appeared during the illness and one urticaria during the prodromal phase. All rashes were associated with itching. These cutaneous manifestations disappeared with median time of 48 h (from 24 h to 6 days).

In our country, only patients with respiratory illness or requiring hospitalization are screened. As a result, it is quite difficult to accurately determine the actual prevalence of COVID‐19 infection and the cutaneous manifestations associated with this viral disease. These factors could explain the lower prevalence of the cutaneous manifestations we found compared to Recalcati S.

By social networking, doctors can inform their colleagues about atypical rash cases they have observed over recent weeks. Some possible specific cases should be highlighted. While of livedoid eruption due to small blood vessel occlusion was previously reported, we teleconsulted three patients (aged from 14 to 22 years) for purplish or red maculopapular +/− vesiculous lesions of the digits of both feet with pain and burning, including chill burns (Fig. 1a,b). They reported no other symptoms and no exposure to cold temperature. Unfortunately, due to a limited number of daily test kits we could not screen these patients. Similar cases have also been reported in social networks with proof of COVID‐19 infection and skin biopsy confirming vasculitis. This particular form of the disease seems to affect mostly young people and is apparently not associated with respiratory symptoms.

Figure 1

Purplish maculopapular and vesiculobullous lesions of the digits of the feet with the aspect of chill burns in a 14‐years‐old boy (a) and a 22‐years‐old woman (b).

With this study, we have observed that cutaneous manifestations are not usual and that in cases of COVID‐19, they are mainly aspecific. However, highlighted clinical features such as chill burns could be a sign of virus carriers or previous infection. Further studies are needed to confirm and better characterize skin reaction in COVID‐19.

Acknowledgement

The patients in this manuscript have given written informed consent to the publication of their case details. The authors also wish to thank Jeffrey Arsham (an American medical translator working at CHU Poitiers, Poitiers, France) for reviewing and editing the original English language manuscript.