key: cord-0811371-1jrbu8ox authors: Drenovska, Kossara; Schmidt, Enno; Vassileva, Snejina title: Covid‐19 pandemic and the skin date: 2020-09-21 journal: Int J Dermatol DOI: 10.1111/ijd.15189 sha: b71d4e362ccc1afbef595c2ca56847de1adf8128 doc_id: 811371 cord_uid: 1jrbu8ox In the beginning of the COVID‐19 outbreak, skin manifestations, if present, were not paid enough attention. Then, the focus moved toward the impact of the prolonged use of personal protective measures in both healthcare workers and patients. In the meantime, attention is increasingly paid to dermatology as a result of the concern for certain groups of dermatologic patients, including those whose condition may worsen by the thorough disinfection measures and those treated with immunosuppressants or immunomodulators. Following patients with psoriasis on biological therapy, as well as other inflammatory and autoimmune cutaneous disorders such as atopic dermatitis, pemphigus, pemphigoid diseases, and skin cancer provoked the interest of dermatologists. Finally, an intriguing question to the dermatologic society was whether skin changes during COVID‐19 infection exist and what could be their diagnostic or prognostic value. Here, we summarize skin conditions during the COVID‐19 pandemic, patient information, and expert recommendations and give an overview about the registries launched to document skin changes during COVID‐19, as well as details about certain patient groups infected with SARS‐CoV‐2, for example, psoriasis, atopic dermatitis, and autoimmune bullous diseases. The current coronavirus disease (COVID-19) manifests itself predominantly as a disorder of the lower respiratory tract leading to pneumonia. It spreads through droplets, aerosols, and contact surfaces and causes fever, fatigue, dry cough, and subsequent shortness of breath. 1 Headache, myalgia, arthralgia, and gastrointestinal symptoms may occur in 5-15% of patients. 2 In the very beginning of the COVID-19 outbreak, data on skin manifestations were scarce. The first look toward dermatology focused on the prevention of the skin and mucous membranes from contact with the infection. Chinese dermatologists were the first to publish a consensus on the adequate measures for topical disinfection in the new pandemic situation. 3 Wearing protective masks, goggles, and gloves, thorough hand washing, as well as frequent use of topical antiseptics became obligatory for a broad spectrum of the population and medical staff. Very soon this resulted in occupational skin damage among medical specialists including facial skin injury on the back of the nose, forehead, and suprazygomatic area. 4, 5 Additionally, damage of the skin barrier through aggressive disinfection or wearing gloves could be considered a prerequisite for provoking or exacerbating of contact or atopic dermatitis, chronic hand eczema, skin candidiasis, etc. The second wave of COVID-19-related dermatological publications was provoked by the concern to all patients with severe dermatological diseases who undergo treatment with biological agents or other types of immunosuppressive or immunomodulatory therapies. 6-8 Psoriasis vulgaris treated with biologics has already been reported to exacerbate from various infectious diseases like zika and dengue virus. 9 Psoriasis was the first dermatosis during the COVID-19 pandemic that drew the attention of dermatologists owing to the wide scope of cytotoxic or biological agents used for its treatment. 10, 11 Patients with hidradenitis suppurativa or other rare diseases who probably face similar problems were provided information on the necessary preventive measures and optional treatment regimens by the European Reference Networks (ERN). 12 Atopic dermatitis patients who demonstrate elevated risk of respiratory comorbidities were advised by the European Academy of Dermatology and Venereology (EADV) task force on atopic dermatitis not to modify by themselves previously stable immune-modulating or immunosuppressive therapies because of increased risk of relapses. 13 Patients with autoimmune bullous dermatoses, especially those suffering from pemphigus and mucous membrane pemphigoid, were informed by the respective AIBD task force on the effects of systemic corticosteroids, steroid-sparing agents, rituximab, and other treatment options during the COVID-19 pandemic. [14] [15] [16] Patients with connective tissue diseases on disease-modifying antirheumatic drugs, biologics, or other immunosuppressive medications were advised to consult their rheumatologist and stop these drugs during an infection, while noninfected patients are required to continue their medication during the epidemic. 17 19, 20 In the meanwhile, dermatologic surgeons and dermoscopists alarmed on the possible delay and risk of complications in diagnosing and treatment of nonmelanoma skin cancer, melanoma, and lymphoma. [21] [22] [23] [24] [25] [26] Reorganization of the work in dermatology units was proposed for maximum safety of both patients and staff. [27] [28] [29] Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) took place among the streptococcal infections, varicella, measles, hepatitis B and C, and AIDS with which dermatologists are often in contact. 30 Patient recommendations and guidelines on specific dermatological conditions during the COVID-19 pandemic are detailed in Table 1 . The most intriguing question to all dermatologists was whether with the disease severity was found, a nonspecific character was presumed. 33 In a French prospective study on the incidence and types of COVID-19-associated cutaneous manifestations, skin involvement was reported in only 4.9% (five patients of 103) and presented as erythematous rash (two patients) and urticaria (two patients). Lesions appeared during the illness or the prodromal phase, affected mainly the face and upper part of the body, were pruritic, and resolved between 24 hours and 6 days. The authors concluded that cutaneous manifestations of COVID-19 were unusual and mostly nonspecific. 34 These initial data were followed by a growing number of individual reports and case series. Morbilliform rash as a presenting symptom of COVID-19 was reported in a 20-year-old previously healthy man from the USA. Future case-controlled studies may potentially confirm AGA as a predictive factor for increased COVID-19 severity and contribute to the development of antiandrogen therapy for SARS- Neonatal rashes Skin rashes in newborns of COVID-19-infected mothers were reported in two boys out of four infants from China. Maculopapular rash scattered throughout the body was observed in one of the boys who was not tested for SARS-CoV-2. The rash resolved rapidly without treatment and was followed by desquamation. Ulcerated facial skin on the forehead was detected in the other boy who was proven to be SARS-CoV-2 negative. Lesions were quickly followed by diffuse red papules that spontaneously healed within 10 days. None of the four newborns of COVID-19-infected mothers developed disease, and no vertical transmission was detected. 63 Kawasaki disease, an acute vasculitis of unknown origin, is another possible but unproven manifestation during COVID-19. It was reported in a 6-month-old, In an online registry launched by the American Academy of Dermatology (AAD) in collaboration with the International League of Dermatological Societies (ILDS), all patients with skin lesions during or following COVID-19 can be reported (Table 2) . 67 The primary purpose is to rapidly collect dermatologic manifestations Furthermore, disease-specific registries have been initiated, for example, for patients with psoriasis (by PsoProtect), atopic dermatitis (by Secure-AD-registry), connective tissues diseases (by EULAR), and autoimmune blistering diseases (by the corresponding EADV task force) ( Table 2 ). Clinical features of 2019 novel coronavirus pneumonia in the early stage from a fever clinic in Beijing Clinical characteristics of Coronavirus Disease 2019 in China Consensus of Chinese experts on protection of skin and mucous membrane barrier for healthcare workers fighting against coronavirus disease 2019 Occupational skin disease among health care workers during the coronavirus (COVID-19) epidemic 6 NICE guideline [NG169] -COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response British Association of Dermatologists (BAD) -Advice for Dermatology HCPs COVID-19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: An Australia/New Zealand consensus statement Azulay-Abulafia L. Zika, chikungunya, and dengue infections as exacerbating factors of psoriasis in patients receiving biological therapy COVID-19 and psoriasis: is it time to limit treatment with immunosuppressants? A call for action Should biologics for psoriasis be interrupted in the era of COVID-19? Patients with rare skin diseases and COVID-19 European Task Force on Atopic Dermatitis (ETFAD) statement on severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-infection and atopic dermatitis Guidance from the EADV Task Force Autoimmune Blistering Diseases during the COVID-19 pandemic Expert recommendations for the management of autoimmune bullous diseases during the COVID-19 pandemic Treatment considerations for patients with pemphigus during the COVID-19 pandemic The COVID-19 outbreak and rheumatologic skin diseases American College of Rheumatology guidance for the management of adult patients with rheumatic disease during the COVID-19 pandemic Systemic immunosuppressive therapy for inflammatory skin diseases in children: Expert consensus-based guidance for clinical decision-making during the COVID-19 pandemic Management of infantile hemangiomas during the COVID pandemic Sebaratnam Deshan Frank. Recommendations on dermatologic surgery during the COVID-19 pandemic Art of performing dermoscopy during the times of coronavirus disease (COVID-19): simple change in approach can save the day! Royal College of Radiologists -Non-melanoma skin cancer (NMSC) and COVID-19 (PDF) Royal College of Radiologists -Guidelines for follow-up and SACT for melanoma during COVID-19 pandemic (PDF) Management of advanced melanoma in the COVID-19 the International Society of Dermatology United States Cutaneous Lymphoma Consortium recommendations for treatment of cutaneous lymphomas during the COVID-19 pandemic What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus? American Academy of Dermatology (AAD) -Managing your practice through the COVID-19 outbreak Recommendations for phototherapy during the COVID-19 pandemic The coronavirus (COVID-19) epidemic and patient safety Acute hemorrhagic edema of infancy after Coronavirus infection with recurrent rash. Case Rep Pediatr Clinical characteristics of children with viral single-and co-infections and a petechial rash Cutaneous manifestations in COVID-19: a first perspective Comment on 'Cutaneous manifestations in COVID-19: a first perspective' by Recalcati S A case of COVID-19 pneumonia in a young male with full body rash as a presenting symptom Rash as a clinical manifestation of COVID19. Photographs of a patient A distinctive skin rash associated with coronavirus disease 2019? Urticarial eruption in COVID-19 infection Comment on: Cutaneous manifestations in COVID-19: a first perspective. Safety concerns of clinical images and skin biopsies Cutaneous manifestations in COVID-19: a new contribution Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients Clinical and histological characterization of vesicular COVID-19 rashes: a prospective study in a tertiary care hospital Marzano Angelo V. Varicella-like exanthem associated with COVID-19 in an 8-yearold girl: a diagnostic clue? Acute acro-ischemia in the child at the time of COVID-19. Dermatol Pediatr. Online ahead of print A case of COVID-19 presenting in clinical picture resembling chilblains disease. First report from the Middle East A new vasculitis at the time of COVID-19 COVID-19) infection induced chilblains: a case report with histopathological findings Mysterious Skin Condition Could be Linked to Coronavirus, Derms Say. Coronavirus Illinois Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France Characterization of acute acro-ischemic lesions in nonhospitalized patients: a case series of 132 patients during the COVID-19 outbreak Coagulopathy and antiphospholipid antibodies in patients with Covid-19 Viral infections and antiphospholipid antibodies COVID-19 can present with a rash and be mistaken for dengue Reply to "COVID-19 can present with a rash and be mistaken for dengue": Petechial rash in a patient with COVID-19 infection A dermatologic manifestation of COVID-19: transient livedo reticularis Histopathological study of 3 cases of new coronavirus pneumonia (COVID-19) with multi-site puncture Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases SARS-COV-2 infection is likely to be androgen mediated A preliminary observation: Male pattern hair loss among hospitalized COVID-19 patients in Spain -A potential clue to the role of androgens in COVID-19 severity What does androgenetic alopecia have to do with COVID-19? An insight into a potential new therapy Infants Born to Mothers With a New Coronavirus (COVID-19) COVID-19 and Kawasaki disease: novel virus and novel case Chinese doctors' skin turns dark after coronavirus recovery Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases The AAD COVID-19 Registry: Crowdsourcing Dermatology in the Age of COVID-19