key: cord-0814618-1vy3i8vf authors: Matar, S.; Oulès, B.; Sohier, P.; Chosidow, O.; Beylot‐Barry, M.; Dupin, N.; Aractingi, S. title: Cutaneous manifestations in SARS‐CoV‐2 infection (COVID‐19): a French experience and a systematic review of the literature date: 2020-06-26 journal: J Eur Acad Dermatol Venereol DOI: 10.1111/jdv.16775 sha: f17df5899ca780b743ab21483dc3b00f1159af16 doc_id: 814618 cord_uid: 1vy3i8vf Skin manifestations have been increasingly reported in the setting of COVID‐19. However, their incidence and presentation are debated, and the role, direct or undirect, of SARS‐CoV‐2 in their pathogenesis has yet to be determined. In this work, we aimed to analyze our experience in a French referral center and to perform a systematic review of the literature to evaluate the incidence and prognosis of cutaneous lesions observed in COVID‐19 patients. Cutaneous manifestations were assessed in COVID‐19 patients admitted to Cochin Hospital (Paris, France) between March 16(th) and April 27(th) 2020. 759 confirmed moderate‐to‐severe COVID‐19 cases were diagnosed in our institution. Eight patients (1%, 6 males, 2 females, mean age 55.6) presented with skin lesions, mainly disseminated maculo‐papular exanthema, but also digitate papulo‐squamous rash (reported in(1)), herpes recurrence, papulo‐vesicular rash and Grover’s disease. The mean delay between respiratory/systemic and dermatological signs was 13 days. Funding resource: none Skin manifestations have been increasingly reported in the setting of COVID-19. However, their incidence and presentation are debated, and the role, direct or undirect, of SARS-CoV-2 in their pathogenesis has yet to be determined. In this work, we aimed to analyze our experience in a French referral center and to perform a systematic review of the literature to evaluate the incidence and prognosis of cutaneous lesions observed in COVID-19 patients. Cutaneous manifestations were assessed in COVID-19 patients admitted to Cochin Hospital (Paris, France) between March 16 th and April 27 th 2020. 759 confirmed moderate-to-severe COVID-19 cases were diagnosed in our institution. Eight patients (1%, 6 males, 2 females, mean age 55.6) presented with skin lesions, mainly disseminated maculo-papular exanthema, but also This article is protected by copyright. All rights reserved digitate papulo-squamous rash (reported in 1 ), herpes recurrence, papulo-vesicular rash and Grover's disease. The mean delay between respiratory/systemic and dermatological signs was 13 days. Our systematic review of the literature identified 56 articles (including our series) evaluating 1020 patients ( in the WHOLE and CONFIRMED cohorts respectively). These rashes were erythematous maculopapular/morbilliform, urticarial/annular, vesicular/varicelliform or petechial/purpuric by order of frequency. Trunk was the preferential localization of rashes. Other cutaneous manifestations included chilblains in 34% patients in the WHOLE cohort, but in only 11.5% cases in the CONFIRMED cohort. Digital necrosis was more frequently reported in the CONFIRMED cohort (11.5% vs 5%). Transient livedo was uncommon (1%). About 70% of all patients experienced pruritus. Other symptoms were burning and pain. The mean delay between the onset of respiratory/systemic symptoms and cutaneous manifestations was around 6.8 days in both cohorts. In some cases, rashes preceded the occurrence of systemic symptoms. When mentioned, chilblains appeared most frequently as a late manifestation. The mean duration of skin lesions was 9 days in both cohorts. We retrieved 6 series, including ours, in which the numbers of both infected patients and patients with skin signs were available 4, 6, 7, 9, 10 . Cutaneous lesions were observed in 38 patients over 2199 COVID-19 cases. Therefore, the mean incidence of cutaneous manifestations in COVID-19 patients was 1.7% ( Figure 1A ). Besides, we investigated whether cutaneous manifestations could correlate with COVID-19 severity. Therefore, we analyzed severity criteria (hospital admission, pneumonia, transfer to Critical Care Unit (CCU), death) in patients of the WHOLE cohort with rashes or chilblains. In patients with rashes, severity was found in 64% of cases and death in 2%, while it was respectively found in 5% and 0% patients with chilblains. We found a statistically significant association between pneumonia, hospitalization, transfer to CCU or death and the occurrence of a rash as compared to chilblains ( Figure 1B) . The incidence of skin signs during COVID-19 is variable in the literature, ranging from 0.2% in China to 20% in North Italy. Our literature analysis indicated that the worldwide incidence is low, This article is protected by copyright. All rights reserved around 1-2%, as we observed in our hospital. Skin lesions were dominated by rashes and chilblains, that seem to present opposite prognosis. However, rashes could not always be discriminated with drug-induced exanthema. Likewise, chilblains pathogenesis in the setting of COVID-19 remains poorly understood and its relationship with SARS-CoV-2 is still unclear. Importantly, in our systematic review of the literature, only 15% of chilblains cases had a proven SARS-CoV-2 infection. In conclusion, this paper provides a comprehensive overview of cutaneous manifestations reported in COVID-19 patients. However, their relationship with SARS-CoV-2 remain to be specified. All data that support the conclusions, including the complete list of references, are available from the authors upon request. Case series, N=88, (7) Multicentric retrospective study, N=1099, (6) Prospective study, N=103, (10) Observational study, N=131, (9) Retrospective study, N=19 eligible, (4) Erythematous rash (2), urticaria (2) This article is protected by copyright. All rights reserved Digitate Papulosquamous Eruption Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection Acral cutaneous lesions in the time of COVID-19. J Accepted Article This article is protected by copyright Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients Characterization of acute acroischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases Clinical Characteristics of Coronavirus Disease 2019 in China Cutaneous manifestations in COVID-19: a first perspective Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France Cutaneous manifestations in COVID-19: the experiences of Barcelona and Rome Cutaneous manifestations in COVID-19: a first perspective Mean duration of cutaneous manifestations, days (range) 9 .0 (20 min -30 d) 9 .0 (20 min -30 d)