Summary COVID‐19 is an infectious disease caused by severe acute respiratory coronavirus 2 (SARS‐CoV‐2). Vesicular skin rashes have been reported as associated with COVID‐19, but there is little information about this cutaneous manifestation. We designed a prospective observational study of patients diagnosed with COVID‐19 who had vesicular lesions. Clinical characterization of skin findings was conducted by dermatologists. When possible, histological analysis and detection of SARS‐CoV‐2 in the content of the vesicles was performed. In total, 24 patients were included. A disseminated pattern was found in 18 patients (75%), and a localized pattern was found in 6 (25%). Median duration of the skin rash was 10 days. Of the 24 patients, 19 (79.2%) developed the skin rash after the onset of COVID‐19 symptoms. Histological examination in two patients was consistent with viral infection, SARS‐CoV‐2 was not detected in four patients. This single‐centre study shows the clinical characteristics of vesicular skin rashes in patients with COVID‐19.

Erythema multiforme-like eruption in patients with COVID-19 infection: clinical and histological findings

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investigate further. First, the analysis did not include patients with similar clinical symptoms, i.e. cough or fever, but were tested negative. Since COVID-19 negative patients, likely with other viral infections, may also have similar skin manifestation as COVID-19 positive patients do, the difference in the prevalence and morphology of skin rash between COVID-19 positive and negative patients warrants comparisons. This would address whether the skin rashes of the three patterns described in the study (erythematous, urticarial and varicelliform) are specific to the COVID-10. Second, it is crucial to measure the viral load in different time points before, during and after the skin rashes in future studies. Viraemia and the skin exanthem may have different time kinetics in different viral infections. For example, viraemia of the measles peaks at the onset of skin rash, 7 whereas viraemia of the parvovirus B19 ends before the onset of skin rash. 8 Hence, the dynamic viral load and its reference to skin rash can become a vital clinical clue for the clinicians to determine the optimal timing (before, during or after the skin rash) to collect the samples for molecular identification. As we have observed the heavy burden of triage and shortage of essential medical goods posed by the outspread of COVID-19, the introduction of an easy clinical assessment tool like classic COVID-19 skin manifestation is a novel path to cope with the challenge that we are facing during the pandemic. However, this will take more studies to build up the validity and reliability. Dermatology's outlook in the COVID-19 is multidimensional, starting from the pathogenesis, public health issues to applying new technologies in clinical practice, the opportunities are infinite. Most importantly, we dermatologists as part of the medical community should contribute our unique perspective in the battle against this formidable pandemic.

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Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website.Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre -including this research content -immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Fig 1. Purpuric skin rash in a patient with COVID-19 bilateral pneumonia, revealing purpuric, coalescing macules on (A) left and (B) right periaxillary regions.

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