Cutaneous Manifestations of COVID-19: A Systematic Review

Abstract

Background: Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), is currently a pandemic. Although pulmonary health has been the primary focus of studies during the early days of COVID-19, development of a comprehensive understanding of this emergent disease requires knowledge of all possible disease manifestations in affected patients. 
 
 Methods: This PRISMA-compliant review focuses on cutaneous manifestations reported in COVID-19 patients. Literature review was conducted using the PubMed database to examine various cutaneous manifestations related to the SARS-CoV-2 infection. Published articles related to search criteria from the onset of the COVID-19 pandemic to June 30, 2020 were included. In total 56 articles were used for data collection. 
 
 Results: Unique to many other symptoms of COVID-19, its cutaneous manifestations have been found in people of all age groups including children. The cutaneous manifestations of COVID-19 are varied and include maculopapular, chilblain-like, urticarial, vesicular, livedoid, and petechial lesions. In addition, rashes are common in multisystem inflammatory syndrome in children (MIS-C), a new and serious health condition that shares symptoms with Kawasaki disease and is likely related to COVID-19. Lastly, personal protective equipment (PPE)-related skin complications are of serious concern since broken cutaneous barriers can create an opening for potential COVID-19 infections and by inadvertently spreading the virus. 
 
 Conclusion and Potential Impact: As this virus continues to spread silently, mainly through asymptomatic carriers, an accurate and rapid identification of these cutaneous manifestations may be vital to early diagnosis and lead to possible better prognosis in COVID-19 patients. This systematic review provides a detailed analysis on the changes in skin morphology related to COVID-19 and discusses plausible underlying molecular mechanisms. Study of these cutaneous manifestations, their pathogenesis as well their significance in human health will help define COVID-19 in its entirety which is a prerequisite to its effective management.

A comparative review on mucocutaneous reactions caused by Covid‐19 infection versus Covid‐19 vaccination

“…Multiple nails and mucocutaneous manifestations of Covid-19, including maculopapular eruptions, urticaria and the acral vasculopathy such as pseudo-chilblain/pernio-like (COVID toe) were considered as primary or evolving signs of the clinical course of the infection. 14 Singh et al 15 infection through skin wounds caused by personal protective equipment. 15 The cutaneous presentations of 507 patients with Covid-19 was reviewed by Zhao et al 16 The skin polymorphic lesions, urticaria, erythema and chilblain-like were prevalent and observed after mean of 9.92 days following the beginning of systemic symptoms.…”

“…14 Singh et al 15 infection through skin wounds caused by personal protective equipment. 15 The cutaneous presentations of 507 patients with Covid-19 was reviewed by Zhao et al 16 The skin polymorphic lesions, urticaria, erythema and chilblain-like were prevalent and observed after mean of 9.92 days following the beginning of systemic symptoms.…”

“…The non-critical reactions were (i) generalized pruritus, (ii) erythematous rash such as maculopapular, morbilliform and papulovesicular eruption, (iii) minor vasculopathies such as chilblain-like and livedoid purpura, (iv) viral exanthem including localized HSV and varicella zoster (VZV) reactivation, (v) erythema nodosum and (vi) urticarial lesions. 13,15,18 Further, the common critical adverse reactions in both groups that require immediate medical attention were (i) angioedema, (ii) erythema multiforme and SJS; however, the severity and incidence of such reactions were greater after Covid infection. 16 On the other hand, most of the patients in the vaccination group with the reactions mentioned above did not require hospitalization, and their conditions were managed with short-term antihistamines and corticosteroids treatment.…”

“…Additionally, the non-critical mucocutaneous reactions that were only seen in Covid-19 infection included (i) minor vasculopathies such as petechia, eruptive cherry angioma and porcelain-like purpura, (ii) ocular and preocular involvement including conjunctivitis and eyelid dermatitis, (iii) generalized pustular figurate erythema and (iv) Sweet's syndrome. 13,15,17 The most common skin manifestations in Covid-19 infection were maculopapular rashes and urticaria, 18 and maculopapular lesions were frequently related to the severe form of the disease (2% mortality rate). 17 However, maculopapular eruption could be related to certain medications.…”

Cutaneous manifestations of Coronavirus Disease 2019

“…4 The cutaneous signs of COVID-19, unlike many other symptoms, have been reported in patients of different ages. 5 Even though early case studies rarely identified skin abnormalities, probably due to the inability to conduct a comprehensive cutaneous examination, subsequent research has revealed considerably greater rates of skin involvement. Several reports were published with descriptions of morbilliform, urticaria, erythema multiforme, Kawasaki, Grover's, vasculitis-like, livedo, retiform, and vasculopathy as well as others.…”