Rarity of cutaneous findings among asymptomatic to mildly symptomatic patients with COVID-19 admitted to a COVID care facility in Delhi, India: an observational study.

Dear Editor, At the peak of the COVID‐19 pandemic, a 500‐bed COVID care centre was started by the government of the National Capital Territory of Delhi, with support from a nonprofit organization of medical doctors, Doctors for You (http://doctorsforyou.org). The aim of this was to provide isolation facilities for asymptomatic or mildly symptomatic patients diagnosed with COVID‐19. The centre was monitored round the clock by a team of medical doctors. Facilities for oxygen administration and transfer to higher medical centres (Delhi government hospitals) were available in case of development of any severe signs or symptoms (SpO2 < 95% on room air or < 90% after supplementing with 100% oxygen). An X‐ray facility was not available at the centre.

All patients were given supervised treatment as per the assessment of the in‐house medical staff. Multivitamins and vitamin C were prescribed for oral administration to all patients as per the protocol established. Hydroxychloroquine and ivermectin were not routinely administered except to a few symptomatic patients, on the judgement of the treating doctors. The patients were discharged after a government‐mandated isolation of 14 days.

In total 1659 COVID‐19‐positive patients admitted to the centre between July and December 2020 were evaluated for cutaneous manifestations. These included 1303 male and 356 female patients, with an age range of 1–88 years (mean ‐ 34·4 years, SD 14). SARS‐CoV2 infection was confirmed using reverse‐transcriptase polymerase chain reaction (302 patients) or rapid antigen test (1357 patients) on nasopharyngeal swabs. Of the total, 151 patients were symptomatic for COVID‐19 (with any one or a combination of fever, dyspnoea, body ache, headache, rhinorrhoea, sore throat, vomiting, diarrhoea, nausea, fatigue, anosmia or dysgeusia), while 1508 were asymptomatic. In total 1399 patients (1310 asymptomatic, 89 symptomatic) had no associated comorbidities, while 260 had one or more of the following conditions: diabetes (18·9%), hypertension (37·6%), asthma, thyroid disease, seizures, psychiatric disorders and malignancy.

Cutaneous examination, including the palms, soles, scalp, hair, nails and mucosa, was conducted on all patients by the resident doctors at the time of admission and was repeated during the stay in case of any new‐onset skin lesions. Specific symptoms like pruritis or burning were also asked for. Any positive finding was subsequently confirmed by a dermatologist. Pre‐existing dermatoses were seen in 38 patients and included prurigo nodularis (one), tinea (17), generalized xerosis with pruritis (eight), acne (one), aquagenic urticaria (one), eczema (one), scabies (three), intertrigo (one), morphoea (one), paederus dermatitis (one), pityriasis versicolor (one), postinflammatory hyperpigmentation (one) and stasis eczema (one). All of these dermatoses persisted after the resolution of COVID‐19 and were not affected by it.

Ten patients developed skin lesions around the onset of COVID‐19 that could be attributed to the infection (Table 1). None of these patients had been given hydroxychloroquine or ivermectin during their stay at the facility. Two patients were hypertensive, while the rest had no comorbid conditions.

Table 1

Description of patients with cutaneous manifestations related to COVID‐19

Age (years); sex	Comorbid conditions	Pre‐existing dermatosis	Duration of skin lesions	Onseta	Symptoms	Description	Sites of involvement	Extent of involvementb	Treatment	Time of resolution
36; M	Hypertension	None	4 day	Before	Asymptomatic	Maculopapular exanthem	Face	4·5%	None	4 days
34; M	None	None	5 days	Before	Itchy, burning	Maculopapular exanthem	Face	4·5%	Mometasone cream, antihistamine	3 days
24; M	None	Acne on back	3 days	After	Itchy	Urticaria	Extremities	9%	Antihistamine	5 days
15; M	None	None	2 days	After	Itchy	Urticaria	Extremities	9%	Antihistamine	2 days
41; M	None	None	1 day	After	Asymptomatic	Maculopapular exanthem	Extremities	36%	None	7 days
30; M	None	Aquagenic rash	1 day	After	Itchy	Maculopapular exanthem	Extremities	27%	Antihistamine	7 days
39; M	None	None	2 days	Before	Itchy	Purpuric flexural exanthem	Trunk	22·5%	Antihistamine	Persistent until discharge
53; M	Hypertension	None	1 day	After	Asymptomatic	Maculopapular exanthem	Trunk	9%	None	7 days
34; M	None	None	1 day	After	Asymptomatic	Papulovesicular exanthem	Trunk and upper limbs	5%	None	7 days
29; M	Anxiety	None	2 days	After	Itchy	Urticaria	Trunk	36%	Antihistamine	5 days

M, male. aBefore or after diagnosis of COVID‐19. bPercentage of body surface area.

Since the onset of the COVID‐19 pandemic, variable estimates of rates of cutaneous manifestations have been put forward. While the initial report from China reported a low incidence of 0·2%, a much higher incidence of about 20% was later reported from Italy. Patterns of involvement of skin were later described by Galván Casas et al. with the aim to ‘help clinicians approach patients with the disease and recognize pauci‐symptomatic cases’. Our findings differ from these as we could not ascertain any specific patterns of involvement in view of the very low incidence (0·6%) of cutaneous findings overall.

It is noteworthy that most of the publications on cutaneous manifestations of COVID‐19 have been from European countries or the USA, with only a few from low‐ and middle‐income countries and in populations with skin of colour. Although the initial assessment in this study was by resident doctors (a limitation of the work), they were trained in recognizing the possible cutaneous findings as well as common dermatological conditions prior to the start of the study, with constant reinforcement during the course of it.

Thus, our study highlights the low incidence of cutaneous manifestations in paucisymptomatic/asymptomatic COVID 19 patients in the largest prospective cohort examined to date. The findings also challenge the assertion of using cutaneous manifestations as a marker of COVID‐19 in the community setting in view of (i) the rarity of skin findings, (ii) the lack of any characteristic skin finding or pattern and (iii) this study being specifically conducted in asymptomatic and mildly symptomatic patients, in whom detection of any specific skin finding might have been beneficial in diagnosing SARS‐CoV2 and preventing spread of the infection.

Acknowledgments

We thank Mr Arun Kumar Mishra, District Magistrate, East Delhi, for invaluable support in running the centre.

Author Contribution

Ananta Khurana: Conceptualization (equal); Data curation (equal); Formal analysis (equal); Investigation (equal); Writing‐original draft (lead); Writing‐review & editing (equal). Aayush Mittal: Conceptualization (equal); Data curation (equal); Formal analysis (equal); Investigation (equal); Writing‐review & editing (equal). Rajat Jain: Conceptualization (equal); Data curation (equal); Formal analysis (equal); Investigation (equal); Writing‐review & editing (equal). Anurag Mishra: Conceptualization (equal); Data curation (equal); Formal analysis (equal); Investigation (equal); Writing‐review & editing (equal). SINU ROSE MATHACHAN: Formal analysis (equal); Methodology (equal); Writing‐original draft (equal).