Clinical Patterns and Morphology of COVID-19 Dermatology

Abstract

Synopsis Coronavirus disease 2019 (COVID-19), an emergent disease caused by severe acute respiratory syndrome cornonavirus 2 (SARS-CoV-2), has rapidly spread throughout the globe since its discovery in December 2019. Although first appreciated to cause pneumonia, numerous organ systems are now known to be involved. The objective of this article is to review the broad spectrum of cutaneous manifestations reported in association with SARS-CoV-2 infection. The most commonly reported cutaneous manifestations associated with COVID-19 infection include pernio (chilblain)-like acral lesions, morbilliform (exanthematous) rash, urticaria, vesicular (varicella-like) eruptions, and vaso-occlusive lesions (livedo racemosa, retiform purpura). It is important to consider SARS-CoV-2 infection in the differential diagnosis of a patient presenting with these lesions in the appropriate clinical context, as cutaneous manifestations may be present in otherwise asymptomatic individuals, or present prior to developing other symptoms of infection. With increased access to diagnostic testing, we are beginning to understand the utility and limitations of currently available assays.

COVID-19 and the Vasculature: Current Aspects and Long-Term Consequences

“…Dermal Microvasculature : Higher incidence rates of cutaneous manifestations such as pernio (chilblain)-like acral lesions compared to pre-pandemic times were associated with mild COVID-19 ( Agnihothri and Fox, 2021 ). Pernio-like acral lesions in COVID-19 patients mostly occur on the toes, are characterized by pink papule that develop into violaceous purpuric lesions and are linked to changes in dermal microvasculature resulting in edema and lymphocyte infiltration ( Agnihothri and Fox, 2021 ). These lesions are not to be confused with skin manifestations observed in severe patients with acral livedoid eruptions and retiform purpura, which arise due to a systemic hypercoagulant state ( Agnihothri and Fox, 2021 ; Do et al, 2021 ).…”

The Impact of COVID-19 Pandemic on Dermatological Conditions: A Novel, Comprehensive Review

“…Livedo racemosa and retiform purpura are vaso-occlusive lesions of the superficial microvasculature. These lesions are associated with elevations in d-dimer and disseminated intravascular coagulopathy (DIC), as seen in those with severe COVID-19 infections [ 96 , 97 ]. Rather than the fine net-like pattern of livedo reticularis [ 98 ].…”

“…In terms of anatomical location, livedo racemosa is more commonly found on the trunk, limbs, and buttocks [ 93 ]. Upon biopsy with immunochemical staining, these vaso-occlusive lesions demonstrate evidence of complement activation with immunoglobulins and microthrombi within the vasculature of the superficial and mid-dermis [ 96 ].…”

“…These lesions correlate with increased severity of COVID-19 infection and mortality. One hundred percent of patients with documented retiform purpura were hospitalized, and 82% developed acute respiratory distress syndrome (ARDS) [ 23 , 96 ]. These vaso-occlusive conditions are consistent with the highest mortality rate of all cutaneous manifestations at 18.2%, with urticaria-like lesions ranking the lowest at 2.2% [ 99 ].…”

“…The mechanism of necrosis may have been due to pressure occlusion rather than inflammation or thrombosis. Additionally, those with purpuric pressure ulcers appeared with no laboratory evidence of DIC [ 96 , 97 ].…”