key: cord-0836825-wtacr6qj
authors: Almutairi, Nawaf; Schwartz, Robert A.
title: Coronavirus Disease‐2019 with Dermatologic Manifestations and Implications: An Unfolding Conundrum
date: 2020-05-09
journal: Dermatol Ther
DOI: 10.1111/dth.13544
sha: 48658885d818655bac8b96cf425f6cc9da8632a0
doc_id: 836825
cord_uid: wtacr6qj

The novel coronavirus SARS‐CoV‐2 has caused Coronavirus Disease‐2019, widely known as COVID‐19, now a pandemic with extraordinary infectivity, mortality, and fomite adhesiveness. As a nosocomial infection for hospital and nursing home patients and health care workers, it represents an extraordinary challenge. The cutaneous markers of this pandemic are being elucidated with preliminary experiences being shared and rapidly communicated. We will review COVID‐19 from both a dermatologic and public health perspective. This article is protected by copyright. All rights reserved.

CoV-2 capable of causing severe disease. The four others produce only mild symptoms. SARS-CoV-2 is a novel coronavirus, an RNA virus closely related to the original SARS-CoV (9). It has been proclaimed as unlikely to have been derived through laboratory manipulation of a related SARS-CoV-like coronavirus (10). measures including frequent hand washing, social distancing by maintaining physical distance from others, covering coughs and sneezes with a tissue or inner elbow and keeping unwashed hands away from the face. The use of masks by everyone when outside is also believed to limit its spread and has been recommended by many countries. Current management basically involves symptomatic treatment, supportive care, isolation and certain experimental therapeutic measures.

Lungs are the most severely affected organ by COVID-19 because the virus enters the host cells via the integral membrane protein angiotensin-converting enzyme 2 (ACE2), which is attached to cellular membranes in the lungs, arteries, heart, kidney, and intestines. It is most abundantly found in the type II alveolar cells of the lungs. The virus uses a special surface glycoprotein called a "spike"

(peplomer) to connect to ACE2 and gain entry into the host cell (10).

The virus also affects gastrointestinal organs as ACE2 is abundantly expressed in the glandular cells of gastric, duodenal and rectal epithelium as well as endothelial cells and enterocytes of the small intestines (11). It also effects the cardiovascular system (12,13), where it causes acute injury to myocardium, more commonly documented in critically ill patients. They also have a high incidence of thromboses and venous thromboembolisms, the presence of which is associated with a poor prognosis (14, 15) .

Pathology: Limited data is currently available about the microscopic changes occurring in various organs with COVID-19 (16) . Autopsy specimens have highlighted pulmonary involvement with a severe pneumonia showing diffuse alveolar damage with diffuse alveolar exudates, findings linked with acute respiratory distress syndrome and severe hypoxemia. Other findings include disseminated intravascular coagulation and a leukoerythroblastic reaction.

Dermatological implications fall into four main categories: cutaneous manifestations of COVID-19, skin changes from COVID-19 lifestyle alterations, cutaneous adverse effects of COVID-19 medications, effects of COVID-19 and its therapy on primary skin diseases and their therapy. COVID-19 has not at least so far been associated with any particular or characteristic skin manifestations.

However, certain dermatoses have been described in these patients, similar to those also observed previously with other respiratory viruses like SARS and MERS (17) . Changes in lifestyle, including prolonged contact to personal protective equipment, and excessive personal hygiene, may produce cutaneous findings, including pressure injury, contact dermatitis, and contact urticaria, as we too have noted too (Fig 12-15 ) (33-39). The exacerbation of pre-existing skin diseases like seborrheic dermatitis, atopic dermatitis, and acne, can be anticipated (33). Most frontline health care workers will develop cutaneous lesions affecting the nasal bridge, hands, cheek, and forehead. As expected, frequent hand hygiene was associated with a higher incidence of hand dermatitis. There is also an enhanced Another important concern is management of patients with autoimmune and chronic inflammatory disorders being treated with biologic drugs or immunosuppressants, psoriasis, atopic dermatitis, connective tissue diseases, and hidradenitis suppurativa (41). European Task force Dermatology Specific Guidelines were published (42), suggesting continuing all immune-modulating treatments, including immuno-suppressive therapy, since exacerbations of underlying diseases can have a large negative impact on patient immunity. It lamented that many conventional systemic immune-modulating agents, such as cyclosporine, may interact with the human body's defense mechanisms against viral disease, but warned that it is not currently known how SARS-CoV-2 affects atopic dermatitis patients and specifically those on immune-modulating therapies.

Public health policy is pivotal and varied (5,43-51). At-home testing and monitoring for possible COVID-19 represent a solid approach to keeping these COVID-19 patients out of understaffed limited-equipment hospitals (52). As another measure to prevent people from being hospitalized, it might be wise to actively discourage health care workers at high-risk, no matter how well-meaning, from being present at health care facilities, given both direct and fomite COVID-19 spread. Since risk is stratified by age, with deaths concentrated at older ages, and underlying co-morbidities, recommendations by us have been made (Table 1) .

Calling for older health care workers to volunteer is questionable. A study of 663 COVID-19 patients from Wuhan, China stressed that patients more than 60 years old and those with chronic diseases were at enhanced risk of severe COVID-19, and more likely to die (43). A larger Chinese study using multivariate Cox regression analysis showed that age≥75, age between 65-74 years, coronary heart disease, cerebrovascular disease, and dyspnea were independent risk factors associated with fatal outcome (44). Neuropsychiatric sequelae of COVID-19 should be a concern (55-61). We 

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