key: cord-0809236-h1xarzwd authors: Dalal, Ashish; Jakhar, Deepak; Agarwal, Vishal; Beniwal, Ravi; Jakhar, Deepak; Agarwal, Vishal; Beniwal, Ravi title: Dermatological findings in SARS‐CoV‐2 positive patients: An observational study from North India date: 2020-06-16 journal: Dermatol Ther DOI: 10.1111/dth.13849 sha: 14d4543c67a649f9fa70120fb7aed175c80f81c2 doc_id: 809236 cord_uid: h1xarzwd A novel coronavirus (severe acute respiratory syndrome corononavirus‐2; SARS‐CoV‐2) has affected millions of people across the world. The coronavirus disease (COVID‐19) resulting from SARS‐CoV‐2 manifests in variable clinical severity, featuring both respiratory and extra‐respiratory symptoms. Dermatological manifestations of COVID‐19 are sparsely reported. To study the various dermatological findings in SARS‐CoV‐2 positive patients in Indian population. This article is protected by copyright. All rights reserved. The outbreak of novel coronavirus disease in the Wuhan, Hubei province of China has now spread all across the world. The cluster of pneumonia cases resulting due to COVID-19 were found to be caused a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical spectrum of SARS-CoV-2 infection appears to be wide, encompassing asymptomatic infection, mild upper respiratory tract illness, and severe viral pneumonia with respiratory failure and even death. [1] [2] [3] Besides the systemic manifestations, skin involvement has also been reported as a part of this viral infection. [4] [5] [6] Dermatological manifestations in COVID-19 can occur either as a direct implication of the SARS-CoV-2 or as a consequence of prolonged wearing of personal protective equipment (PPE). [4] [5] [6] [7] [8] The spectrum of dermatological manifestations owing to the disease process needs elaboration and data from various regions across the globe, involving different ethnicity, need to be processed. The present study elaborates various dermatological findings in SARS-CoV-2 positive patients from North India. This article is protected by copyright. All rights reserved. The study was approved by institutional ethical committee (IEC). The study was conducted for three weeks and all consecutive patients, who were found to be SARS-CoV-2 positive after RT-PCR test report (Nasopharyngeal swab) and admitted in the hospital, were enrolled for the study. Two authors, AD and VA, did a complete dermatological evaluation for the patients according to their duty roster. Disease severity was assessed as per world health organization (WHO) definition and guidelines. 9 Only asymptomatic and mild/moderate disease patients were included in the study. Symptoms in mild disease were: fever >38 0 C, sore throat, cough, fatigue and headache, and symptoms in moderate disease included: fever, cough, dyspnoea, fast breathing, respiratory rate 15-30/min and SpO2 90%-94%. Patients with severe-to-critical disease and admitted in the intensive care unit (ICU) were not included in the study, since complete dermatological evaluation was not possible. Clinical photography was not done due to lack of guidelines for clinical photography during COVID-19 and risk of transmission of SARS-CoV-2 through the device. Statistical analysis was done using IBM ® SPSS software, version 21. Numerical data was presented as number and standard deviation (SD); and categorical data was presented as number and percentage. The level of significance, wherever applicable, was taken as p<0.05 This article is protected by copyright. All rights reserved. A total of 102 positive cases (95 males and 7 females) were included in the study. The mean age of the patients was 39.30±17.9 years. Out of total 102 patients, 27 presented with mild/moderate symptoms. Amongst 102 patients, thirteen patients (12.7%) were found to have dermatological manifestations. Three (2.9%) had maculopapular rash, two (1.9%) had urticarial lesions and eight (7.8%) patients had itching without any specific cutaneous signs [ Table 1 ]. Trunk was the most frequently affected area, followed by the extremities. No palm/sole involvement; and mucosal signs and symptoms were detected. None of the patient had any pre-existing dermatoses. The evolution of maculopapular rash was on day 2 of fever in two patients and day 3 of fever in one patient. The maculopapular rash was centripetal in distribution. All patients, along with symptomatic treatment, were given tab hydroxychloroquine (HCQS) 400mg twice daily on day one, then 200mg twice daily for ten days. If patients showed fever, then after ECG evaluation, tab azithromycin 500mg once a day a state of hypercoagulability has been proposed behind this manifestation. [15] [16] Kolivras et al demonstrated that histopathology in a chilblain like lesion shows papillary dermal edema and perivascular and peri-eccrine lymphocytic infiltration along with scatter necrotic keratinocytes in the superficial layers of epidermis. 17 This chilblain like presentation acts as a good prognostic factor in young individuals, whereas it is a bad prognostic factor in older individuals. The pathogenicity behind the development of chill blain lesions also differ owing to a differing immune response in both age groups. In younger age groups, chill blain like lesions occur as a consequence of immune response generating Type-1 interferons (IFN-I), but in older age group, the presentation is due to a delayed or insufficient IFN-I response. 17 This article is protected by copyright. All rights reserved. ischemia like lesions tend to show elevated levels of D-dimer, fibrinogen and fibrinogen degradation product (FDP) and prolonged prothrombin time (PT). 18 The histopathological changes in various cutaneous lesions of COVID-19 have also been studied. 16 Maculopapular rash in its early stage shows telengiectatic small blood vessels in upper dermis. As it progresses, Langerhans cells also shows up. Purpuric maculopapular rash shows perivascular lymphocytic infiltration with eosinophils and extravasated erythrocytes; and increased Langerhans cells. Severe macular hemorrhagic rash shows intravascular microthrombi in upper dermal vessels. Lesions mimicking Grover disease reveals dykeratosis, multinucleated giant cells and necrotic keratinocytes. 19 The findings in our study included only maculopapular rash, urticarial lesions and non-specific pruritus. None of our patients showed acral ischemia or chillblain like lesions, varicella like lesions, vesicular eruptions, livedo or necrosis. Different ethnicity, skin of color, differences in the infective strains of SARS-CoV-2 and inclusion of only mild-to-moderate disease in our patients may be the possible explanation. This study suggests that asymptomatic and mild-to-moderate disease may show non-specific and subtle dermatological manifestations. Vasculopathy related skin lesions may be more specific for COVID-19 and may indicate severity. 20 This article is protected by copyright. All rights reserved. Our study has limitations in the form of lack of clinical photography, small sample size, exclusion of patients with severe-to-critical disease and lack of histopathological correlation. Dermatological manifestations in our study was shown by small number of patients. Mild-to-moderate disease may show non-specific and subtle dermatological manifestations. The presentation and frequency of cutaneous manifestations in COVID-19 may vary in different population groups. WHO. Coronavirus disease 2019 (COVID -19) Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan Clinical features of patients infected with 2019 novel coronavirus in Wuhan Cutaneous manifestations in COVID-19: a first perspective COVID-19 can present with a rash and be mistaken for Dengue Dermatology staff participate in fight against Covid-19 in China Skin damage among healthcare workers managing coronavirus disease-2019 Letter from the Editor: Occupational skin disease among healthcare workers during the Coronavirus (COVID-19) epidemic Clinical management of COVID-19. World Health Organization Coronavirus disease (COVID-19): An updated review based on current knowledge and existing literature for dermatologists This article is protected by copyright. All rights reserved Atypical erythema nodosum in a patient with COVID-19 pneumonia Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases A case of COVID-19 presenting in clinical picture resembling chilblains disease Cutaneous manifestations in COVID-19: a new contribution Vascular skin symptoms in COVID-19: a french observational study Acute limb ischemia in patients with COVID-19 pneumonia COVID-19) infection-induced chilblains: a case report with histopathological findings Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acroischemia. ZhonghuaXue Ye Xue Za Zhi Clinical and histopathological study of skin dermatoses in patients affected by COVID-19 infection in the Northern part of Italy Diagnostic and prognostic values of cutaneous manifestations in COVID-19 Table 1: Dermatological manifestations in SARS-CoV-2 positive patients This article is protected by copyright. All rights reserved.