key: cord-0935704-xzeq31e2
authors: Guelimi, R.; Salle, R.; Dousset, L.; Assier, H.; Fourati, S.; Bhujoo, Z.; Barbarot, S.; Boulard, C.; Cazanave, C.; Colin, A.; Kostrzewa, E.; Lesort, C.; Levy Roy, A.; Lombart, F.; Marco Bonnet, J.; Marty, L.; Monfort, J.B.; Riffaud, L.; Samimi, M.; Tardieu, M.; Sbidian, E.; Wolkenstein, P.; Le Cleach, L.; Beylot‐Barry, M.
title: Non‐acral skin manifestations during the COVID‐19 epidemic: COVIDSKIN study by the French Society of Dermatology
date: 2021-05-12
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17322
sha: c2ca4f203ecd38b8cd9bc3adf7d3bf01c02c95de
doc_id: 935704
cord_uid: xzeq31e2

A variety of skin manifestations occurring during the COVID-19 pandemic have been reported since March 2020.1 The most reported were chilblain-like lesions, widespread urticaria, maculopapular eruptions, vesicular eruptions and vascular lesions such as livedo or necrosis.1-3.

Dear Editor, A variety of skin manifestations occurring during the COVID-19 pandemic have been reported since March 2020. 1 The most reported were chilblain-like lesions, widespread urticaria, maculopapular eruptions, vesicular eruptions and vascular lesions such as livedo or necrosis. [1] [2] [3] Cutaneous manifestations are rare with a frequency estimated around 2% of patients with a biologically confirmed COVID-19. [4] [5] [6] [7] A national survey, COVIDSKIN study of the French Society of Dermatology, was carried out from March 30 to June 11, 2020, asking hospital and private physicians to report, using a standardized questionnaire, cases of skin manifestations in patients with COVID-19 clinically suspected. We report skin manifestations excluding acral manifestations, described separately. 3 We aimed to describe the characteristics, the skin manifestations and the biological diagnostic tests' results of suspected COVID-19 patients.

Among the 492 collected cases, after excluding 311 patients with acral manifestations and 65 for whom no COVID-19 tests were performed, we included 116 patients: 52 had positive COVID-19 tests (45 positive RT-PCR, eight positive serology; including one patient positive for both) and were then considered as 'confirmed COVID-19 group' and 64 who had negative tests (15 with negative RT-PCR and 49 with negative results for both RT-PCR and serology) but who were clinically suspected, then considered as 'unconfirmed COVID-19 group'. The available photographed manifestations were classified by four dermatologists according to Galv an Casas et al. 1 (maculopapular eruptions, urticaria, vesicular rash, necrosis/livedo and other eruptions).

The overall median age was 38 [interquartile range (IQR) 28-52]. All the hospitalized patients were in the confirmed group (25/52) except for two patients with negative RT-PCR. Four patients were died, all from the COVID-19-confirmed group. Median time between the first infectious symptoms when present (n = 86) and RT-PCR was 6 days (IQR 3-13) and median time to serology was 26.5 days (IQR 13-33.3). Median time between the first infectious symptoms and cutaneous manifestations was 7 days (IQR 3-16). Patients' and characteristics and biological tests' are summarized in Table 1 .

Pictures of the lesions were available for 71 patients (Fig. 1) . The most common manifestation was maculopapular eruption. The frequency and distribution of the types of skin manifestations did not significantly differ between the confirmed and unconfirmed COVID-19 patients (P = 0.199), as summarized in Data are presented as n (%) unless otherwise indicated. †Histologically confirmed diagnosis. ‡Deceased patients: maculopapular rashes, n = 2; urticaria, n = 1; purpura/livedo, n = 1. Table 1 , although urticarial eruptions seemed more frequent among confirmed patients. In the confirmed group, the frequency and distribution of the types of manifestations did not differ between hospitalized and non-hospitalized patients. Previously, two large retrospective series classified respectively 304 COVID-19 and 126 cases found the following types of nonacral manifestations' frequencies: 58-61% maculopapular eruptions; 21-24% urticaria; 11-14% vesicular eruptions; and 7-9% livedo/necrosis. 1,2 We observed these manifestations in similar proportions, especially among patients with confirmed COVID-19 (Table 1) . We could not exclude the possibility of false negative for some patients, specifically for those who reported anosmia/ageusia and when RT-PCR was not followed by serological testing, while this probability was low for RT-PCR and seronegative patients. Indeed, asymptomatic COVID-19 patients have a similar rate of seroconversion than symptomatic patients and the 58 serologies performed had a sensitivity and specificity above 98% in the timeframe they were performed. 8 As previously stated, given the dermatological manifestations' heterogeneity, possible differential diagnoses, classification bias and the absence of gold-standard test to exclude COVID-19, it was not possible to determine which cutaneous manifestations are directly related or not to the infection. 9,10 Further prospective studies with systematic dermatological examination of patients with proven COVID-19 are needed to establish a formal association between infection and specific cutaneous manifestations.

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The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries

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