key: cord-286227-foeb0g7u authors: Potekaev, Nikolai N.; Zhukova, Olga V.; Protsenko, Denis N.; Demina, Olga M.; Khlystova, Elena A.; Bogin, Vlad title: Clinical characteristics of dermatologic manifestations of COVID‐19 infection: case series of 15 patients, review of literature, and proposed etiological classification date: 2020-07-03 journal: Int J Dermatol DOI: 10.1111/ijd.15030 sha: doc_id: 286227 cord_uid: foeb0g7u nan Presently, the exact dermatologic manifestations of COVID-19 infection, its characteristics, prevalence, temporal relationship to other clinical findings, and severity of underlying illness are still being evaluated. The first report on such skin lesions was published by Recalcarti et al. 1 According to Su and Lee, differentiating the skin lesions related to COVID-19 from other infectious exanthems and dermatoses can be challenging. 2 They excluded 60 of 148 patients from their study as they were taking new medications prior to developing symptoms of COVID-19 infection, indicating that a drug allergic reaction could not be excluded as a cause of their dermatologic presentation. A total of 20.4% of patients included in the study were diagnosed with erythematous rash, diffuse urticaria, and chickenpox-like vesicular rashes. Guan W, Ni Z., Hu Yu et al. 3 reported a very low incidence of skin manifestations in Chinese patients with COVID-19, where it was observed in 0.2% of the patients. This study does not provide a detailed description of the skin lesions nor the criteria for its diagnosis. According to Est ebanez et al., erythema and urticaria may be some of the first symptoms of severe COVID-19 infection. The described 28-year-old woman, 13 days after laboratory diagnosis, developed pruritic lesions of the heels described as confluent "erythematous-yellowish" papules; 3 days later, they appeared as pruritic, hardened, erythematous plaques. The clinical differential diagnosis included urticaria, urticarial vasculitis, idiopathic plantar hidradenitis, and neutrophilic dermatosis. No biopsy was obtained, and the author did not specify whether the skin lesions could have represented Cutaneous Adverse Drug Reactions (CADR). 4 Iviensan et al. 5 A 74-year-old male patient with COVID-19 pneumonia was diagnosed with polymorphic cutaneous vasculitis (Fig. 2) , which was present on admission. Its progression coincided with an increase in the severity of illness. The skin manifestations started to subside as the patient started to improve. A 59-year-old male patient presented with fever of 39°C and a rash of the lower extremities in combination with hemorrhagic elements which were consistent with polymorphic cutaneous vasculitis ( Fig. 3a ,b). The patient rapidly deteriorated and was admitted to the intensive care unit and placed on mechanical ventilation. CT of the chest showed ARDS with 75% involvement of the lung parenchyma. A 47-year-old female patient with COVID-19 pneumonia developed acral urticarial highly pruritic rash on upper and lower extremities 5 days after the laboratory diagnosis (Fig. 7a, b ). The patient received oral glucocorticosteroids with quick resolution of the rash. A 71-year-old male patient, 2 weeks prior to our examination, developed papulovesicular eruptions while having escalating clinical symptoms of COVID-19 infection (fever, weakness, cough, shortness of breath) (Fig. 8a,b) . From the history, it is also known that papular and papulovesicular rashes occurred before hospitalization and treatment, which excludes CADR and indicates its correlation with the onset of COVID-19 infection. A 46-year-old female patient with confirmed COVID-19 infection and bilateral pneumonia presented with papulovesicular elements in the chest area (Fig. 9) . The appearance of a rash was noted after an increase in body temperature, accompanied by sweating. A 53-year-old woman presented with disseminated pink-red maculopapular rash resembling that of measles that developed on day 7 of the disease, involving the trunk and upper and lower extremities (Fig. 11 ). An 83-year-old patient was admitted to the hospital in serious condition with 75% parenchymal pulmonary involvement. While receiving hydroxychloroquine and azithromycin, an extensive skin rash developed that involved the entire trunk with a transition to the shoulders and buttocks (Fig. 12a-c) . The rash consisted of erythematous spots of bluish-pink color, merging into extensive plaques. Some of the elements were ring shaped, which made the skin lesion resemble exudative erythema multiforme. The administration of parenteral glucocorticosteroids quickly led to regression of the rash. A 56-year-old male patient with COVID-19 infection presented with skin lesions, also called "bilateral inguinal purple rash." Large pink-red plaques were observed in both inguinal folds with a transition to the inner thighs, with a brownish tint and abundance of follicular papules along the periphery (Fig. 13) . The patient was receiving hydroxychloroquine, ceftriaxone, and azithromycin. Rashes in the inguinal areas appeared during treatment, gradually spreading via formation of follicular papules along the A 60-year-old female patient with COVID-19 infection presented with large purple plaques on the abdomen with umbilical sparing with numerous thick papules along the periphery. Skin lesions appeared several days after the start of combined antiviral and antibacterial therapy for pneumonia, and in the second week of treatment, disseminated erythematic papules appeared on the breasts, chest, abdomen, and hips (Fig. 14) . A 55-year-old male patient with COVID-19 pneumonia developed large bright red foci on the extensor surfaces of both upper extremities, which subsequently became pale after the addition of systemic glucocorticosteroids to the treatment regimen (Fig. 15 ). At the time of the onset of skin rash, the patient was not receiving any concomitant therapy. The weaknesses of this case series stem from the lack of histological analysis of observed cutaneous lesions and, in some cases, from inability to evaluate the patients at the time of symptom onset. In three cases, despite our suspicion of viral etiology, CADR could not be excluded. As medical facilities become more comfortable with handling patients with COVID-19 infection, the aforementioned limitations will likely become less significant. In conclusion it is important to reiterate that the significance of Cutaneous manifestations in COVID-19: a first perspective Viral exanthem in COVID-19, a clinical enigma with biological significance Clinical characteristics of coronavirus disease 2019 in China Cutaneous manifestations in COVID-19: a new contribution A dermatologic manifestation of COVID-19: Transient livedo reticularis COVID-19 can present with a rash and be mistaken for Dengue Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases Digitate papulosquamous eruption associated with severe acute respiratory syndrome Coronavirus 2 infection Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases A case of COVID-19 pneumonia in a young male with full body rash as a presenting symptom Cutaneous manifestation of COVID-19 in images: a case report SARS-CoV-2 infection presenting as a febrile rash Varicellalike exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients