key: cord-1012137-wfxcegf0
authors: Kittler, H.; Tschandl, P.; Weninger, W.
title: Cutaneous signs in SARS‐CoV‐2 infection: a plea for more rigorous peer review in the time of COVID‐19
date: 2020-09-10
journal: Br J Dermatol
DOI: 10.1111/bjd.19429
sha: 29b402672ba2f4b0fda56564e964fc9e9a72d8a7
doc_id: 1012137
cord_uid: wfxcegf0

Many systemic viral infections are accompanied by skin rashes of variable morphology, some of them pathognomonic for the respective disease. Limited information is available about cutaneous signs in the course of SARS CoV-2 infection. Anecdotal observations and small case series collected from all over the globe have described a plethora of skin signs including, among others, Dengue-like, urticarial, crusted and papular, herpetiform and varicella-like rashes, and chillblain-like lesions ("COVID-toes").

Anecdotal observations and small case series collected from around the globe have described a plethora of skin signs including (among others) Dengue-like, 1 urticarial, 2,3 crusted and papular, 4 herpetiform 5 and varicella-like rashes 6 and chilblain-like lesions ('COVID toes'). 7 Rather than being specific to COVID-19, these different manifestations may represent coincidental skin disease in patients infected with SARS-CoV-2. Moreover, some of the included patients represented suspect cases that were not tested or tested negative for the virus, at least by polymerase chain reaction. Both the character and the frequency of skin symptoms in COVID-19 remain obscure. The first reports from China suggested that skin symptoms are rare; however, it is unclear whether there was specific dermatological expertise involved in the examination of these patients. 8 Of 1099 patients only four (0Á2%) developed a rash. Later, Recalcati reported from Lecco, Italy that 18 of 88 patients (20%) with COVID-19 developed skin symptoms. 2 However, these 88 patients were taken from a larger sample of 148 patients and the total population of patients infected with SARS-CoV-2 in Lecco remains unknown. Owing to these limitations, the prevalence of 20% reported by Recalcati does not represent a reasonable estimate of the frequency of skin symptoms in all patients infected with SARS-CoV-2. Despite these objections, this number has been used as a reference in subsequent publications. 3 A large proportion of reports on skin signs in COVID-19 underwent expedited review; some of these reports were even accepted by peer-reviewed journals on the day of submission. Of 259 articles published on COVID-19 in the top five dermatology journals between 1 January 2020 and 30 June 2020, 142 reported the date of receipt. For these articles, the median time from submission to acceptance was 6 days [interquartile range (IQR) 14 days] and 12 articles (8Á5%) were reported to have been accepted on the day of submission. By comparison, only 4Á9% (n = 21) of other articles were reported to have been accepted on the day of submission. The median time from submission to acceptance of articles that covered topics other than COVID-19 (n = 431) and that were published during the same time period and in the same journal was significantly longer (median 33 days, IQR 49Á5 days; P < 0Á001) (Figure 1 ). This has also been observed in other fields of medicine, not just dermatology.

As of 30 June 2020, a PubMed search entering the keyword 'COVID-19' yields 25 428 articles published in 2020. Of all publications that provided valid publication history timelines in PubMed (n = 5150), no revision was reported in 54Á4% (n = 2800). The median time from submission to acceptance was 16 days (IQR 24 days) for 'COVID-19' studies, which was significantly shorter than for articles published in the same time period under the keywords 'H1N1' (median 34 days, IQR 49 days; P < 0Á001), 'melanoma' (42 days, IQR 44 days; P < 0Á001) and 'psoriasis' (median 33 days, IQR 42Á5 days; P < 0Á001).

We assume that under normal circumstances these studies would not have been published so quickly, if at all. Peer review is lengthy and time-consuming. Reviewers ask critical questions, but they also provide valuable feedback, which helps researchers to improve their manuscripts before publication. If this control mechanism is suspended, the result may be unfiltered news that may mislead the medical community and unsettle clinicians and patients alike. Indeed, recent reports of 'COVID toes' as a sign of viral infection, and the emergence of Kawasaki syndrome-like disease in children, has resulted in heated debates in the dermatology community. We acknowledge that in a time of an unprecedented health crisis there is a need for a more immediate exchange of information, even if it is of uncertain significance. We believe that preprint servers such as bioRxiv and medRxiv are more suitable for this type of information rather than peer-reviewed journals.

What we need now is a cooling-down phase. The time will come when the dust has settled, and we will get a clearer view on the specificity of skin symptoms in patients infected with SARS-CoV-2. We appeal to both the researchers who seek the opportunity to publish in high-impact journals, and the competitive journals and editors who seek the opportunity to attract attention. Leave the hype to the mass media and the propagation of immediate unfiltered news to Twitter and company. Do not suspend peer review! H. Kittler iD , P. Tschandl iD and W. Weninger 

COVID-19 can present with a rash and be mistaken for dengue

Cutaneous manifestations in COVID-19: a first perspective

Urticarial eruption in COVID-19 infection

Cutaneous clinico-pathological findings in three COVID-19-positive patients observed in the metropolitan area of

Cutaneous manifestations in COVID-19: the experiences of Barcelona and Rome

Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients

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

Conflicts of interest: The authors declare they have no conflicts of interest

Paucity of COVID-19 dermatology literature from low-and middle-income countries DOI: 10.1111/bjd.19505 DEAR EDITOR, Since emerging in December 2019, coronavirus disease 2019 (COVID-19) has become a global pandemic with community transmission now reported in most World Health Organization regions. 1 As the pandemic progresses, there have been a growing number of reports of cutaneous manifestations and discussions of how COVID-19 has impacted clinical practice. [2] [3] [4] We hypothesized that many such dermatology publications may be authored from high-income countries, raising questions about case representation and the generalizability and comprehensiveness of COVID-19-related insights, discourse and guidance in our field.To address this question, we assessed authors' countries of professional affiliation in the published COVID-19 dermatology literature. We searched PubMed/MEDLINE from 1 November 2019 through 12 June 2020 and Embase from 1 January 2019 through 14 June 2020 using dermatological keywords and a modified search strategy based on the Medical Library Association Clinical Librarians Caucus' COVID-19 hedge (search terms available upon request), identifying 988 unique results. Two reviewers independently conducted title and abstract reviews to identify articles related to dermatology and COVID-19. Categorization discrepancies were discussed to consensus. In total 553 articles met the inclusion criteria and were further classified by article theme and author country affiliation. Country affiliation categorization was based on the World Bank's income classification scheme (HIC, UMIC, LMIC, LICrespectively countries with high, upper middle, lower middle and low income), 5 with an additional distinct category for China, which we suspected would be uniquely well represented in the literature. UMIC and LMIC were combined into middle-income country (MIC) for clarity and pragmatism of analysis.The most common article theme was cutaneous manifestations of COVID-19 (190, 34Á4%), followed by pandemic impacts on the field of dermatology (139, 25Á1%), management of specific dermatological conditions during the pandemic (132, 23Á9%), dermatological issues associated with personal protective equipment use and hygiene practices (65, 11Á8%), cutaneous adverse effects of COVID-19 drugs (16, 2Á9%), and dermatological drugs and conditions modulating COVID-19 disease severity (11, 2Á0%). The majority of first authors were affiliated with HICs (419, 75Á8%), followed by MICs (98, 17Á7%), exclusive of China (36, 6Á5%). When considering the country affiliation of all authors, 440 (79Á6%) papers had an author from an HIC, 117 (21Á2%) had an author from an MIC, and 43 (7Á8%) had an author from China. Our analysis identified no COVID-19 dermatology publications listing authors from LICs. A visualization of our results illustrates a lower density of articles describing COVID-19 cutaneous manifestations originating from countries in Africa and Central and South America, compared with a higher density of articles from European countries and the USA (Figure 1 ).This paucity of published COVID-19 dermatological articles from MICs and LICs is consistent with COVID-19 publication trends generally, 6 and likely reflects trends in academia outside of the current pandemic. Nonetheless, it has important implications for current clinical practice and pandemic control. Dermatological manifestations can be the presenting symptom of COVID-19, 3 and our ability to diagnose and treat these patients rapidly relies on identifying these symptoms, which may vary in presentation based on skin type and geographical region. Consistent with a recent study demonstrating a lack of representation of images of skin of colour in the COVID-19 dermatological literature, 7 the current paucity of MIC and LIC representation in the literature suggests our understanding of its cutaneous manifestations is incomplete.Accordingly, dermatology journals must prioritize soliciting and publishing submissions from MICs and LICs on COVID-19. Inclusion of more cases of COVID-19 with cutaneous manifestations and discourse about clinical practice in dermatology during the pandemic from more regions of the world and in differently resourced practice settings is integral to the improved management of COVID-19 and other dermatological conditions. This is true not only in MICs and LICs, but also in all countries and contexts with diverse patient populations and resource settings. Our findings may also reflect a need for the field to invest in promoting dermatology research training and opportunities globally.Limitations of this study include the use of author country affiliation as a proxy for case country location, which may miss publications based on data registries that include cases from LICs, but are published with only HIC authors, like the