Cutaneous manifestations of COVID-19: A preliminary review.

To the Editor: First described in Wuhan, China, in late December 2019, coronavirus disease 2019 (COVID-19) has emerged as a global public health emergency. Countries across the world are rapidly reporting new infections and case fatalities. As the COVID-19 pandemic rapidly evolves, understanding symptoms and clinical characteristics of affected persons is essential. Patients with COVID-19 often present with fever, cough, and fatigue, although organ-specific symptoms have been reported. , The primary aim of this study was to systematically review published and preprint articles describing cutaneous symptoms associated with COVID-19 presentation.

Literature for this review was identified by searching the PubMed/MEDLINE database for published articles and the medRxiv database for preprint ones. Search terms “COVID-19,” “2019-nCoV,” and “coronavirus” were used to capture articles associated with COVID-19. All articles published between December 31, 2019, and May 3, 2020, were included. Screening and review of articles were conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (Fig 1 ). Reviewers conducted full-text reviews for 625 articles to identify English-language studies describing cutaneous manifestations associated with COVID-19.

Fig 1

PRISMA diagram for inclusion of records in systematic review.

Forty-six articles met inclusion criteria, with a pooled total of 998 unique patients from 9 countries with skin manifestations related to COVID-19. A minority of articles contained more than 5 patients with cutaneous presentations of COVID-19 (Table I ). The most commonly reported skin finding was chilblain-like lesions (402, 40.2%), followed by maculopapular lesions (227, 22.7%), urticarial lesions (89, 8.9%), vesicular lesions (64, 6.4%), livedoid and necrotic lesions (28, 2.8%), and other or nondescript rashes and skin lesions (192, 19.8%). Pain and burning was reported in at least 85 cases, and itch was reported in at least 256 cases. Reported prevalence of cutaneous manifestations of COVID-19 were variable. In non–case report studies that contained patients with and without skin findings related to COVID-19, skin disease prevalence varied from 0.19% to 20.45%. ,

Table I

Articles with more than 5 patients that described skin disease associated with presentation of COVID-19

Article	Year and location	Design	Population	Cases with cutaneous manifestations related to COVID-19 (%)	Cutaneous manifestations	Anatomic location of skin lesion	Notes
Bouaziz et al4	2020; France	Retrospective; multicenter	14	14 (100)	Inflammatory lesions (7), vascular lesions (7)		COVID-19 symptoms before skin lesion onset (14)
Duong et al5	2020; France	Prospective; crowdsourced social media	295	295 (100)	Chilblain-like lesion (146), other skin eruption (149)
Fernandez-Nieto et al6	2020; Spain	Retrospective	346	132 (38.2)∗	Chilblain-like lesion (95), erythema multiform–like lesion (37)	Chilblain-like lesions (hand [33], feet [73]), erythema multiform–like lesions (hand [8], feet [35])	Skin lesion at COVID-19 symptom onset (3), COVID-19 symptoms before skin lesion onset (16); no diagnosis of pneumonia (132/132)
Galván Casas et al7	2020; Spain	Prospective; crowdsourced survey	429	375 (87.4)	Maculopapular lesion (176), urticarial lesion (73), pseudochilblain lesion (71), vesicular lesion (34), livedoid/necrotic lesion (21)	Pseudochilblain (acral), vesicular (some trunk, limbs, diffuse), urticarial (mostly trunk or diffuse, few palmar), maculopapular (diffuse, few extremities), livedoid/necrotic (trunk, acral)	Itch (213), pain (32), burning (22)
Landa et al8	2020; Spain	Retrospective; multicenter	6	6 (100)	Chilblain-like lesions (6)	Foot (5), hand and foot (1)	Pain (3), itch (2); skin lesion led to diagnosis of pneumonia (1)
Marzano et al9	2020; Italy	Prospective; multicenter	22	22 (100)	Varicella-like exanthem (22)	Trunk (18), trunk and limbs (4)	Itch (8), pain (2), burning (2), itch/burning (1); COVID-19 symptoms usually before skin findings
Piccolo et al10	2020; Italy	Prospective; crowdsourced survey	63	63 (100)	Chilblain-like lesions ([63: 54 had photos]; 31/54 erythematous-edematous, 23/54 blistering)	Feet (86%), hands (6%), both (7%)	Pain (27%), itch (27%), pain/itch (21%); most patients had lesions at diagnosis
Recalcati11	2020; Italy	Prospective; single institution	88	18 (20.5)	Erythematous rash (14), widespread urticaria (3), chicken pox–like vesicles (1)	Trunk was most involved region	Cutaneous manifestations at onset (8); cutaneous manifestation developed after hospitalization (10)
Recalcati et al12	2020; Italy	Prospective; single institution	121	14 (11.6)	Erythematoviolaceus acral rash, digital welling	Feet (8), hands (4), hands and feet (2)	Itch (3); children (11), young adults (3)

COVID-19, Coronavirus disease 2019.

Nonacral skin lesions excluded from counts per article methods.

Higher reporting of chilblain-like lesions may have occurred because some studies focused on this finding or anatomic region specifically. , , Disparities among reported cutaneous manifestation prevalence suggest a potential underreporting of skin diseases associated with COVID-19. This is concerning because cutaneous manifestations can be the presenting complaint of COVID-19 patients amid mild or absent more common COVID-19 symptoms. , , For instance, the presenting symptom for one patient with COVID-19 was urticaria; the patient sought care twice before being identified as having coronavirus. Misclassification of COVID-19 patients as not having the disease can hinder community transmission control efforts because of potential asymptomatic transmission. Future studies should include race/ethnicity information because some skin findings may be more common in skin of color. Limitations of this systematic review include few large or comprehensive studies, and that some articles included patients with suspected but unverified COVID-19.

The American Academy of Dermatology has recently launched a much-needed COVID-19 registry to track cutaneous manifestations associated with disease presentation. , Careful documentation and robust reporting of cutaneous manifestations associated with COVID-19 are needed to augment our understanding of disease presentation and epidemiology. Improved understanding of cutaneous manifestations, comorbidities, and treatments will enhance our ability to provide better clinical care and support our colleagues on the front lines of this rapidly evolving pandemic.