Dermatological aspects of SARS-CoV-2 infection: mechanisms and manifestations

Abstract

The human infection caused by the novel SARS-CoV-2 is a public health emergency of international concern. Although the disease associated to this virus, named COVID-19, mainly affects the lungs, the infection can spread to extrapulmonary tissues, causing multiorgan involvement in severely ill patients. The broad infective capacity of SARS-CoV-2 is related to the pattern of expression of the viral entry factors ACE2 and TMPRSS2 in human tissues. As such, the respiratory and gastrointestinal tracts are at high risk for SARS-CoV-2 infection due to their high expression of ACE2 and TMPRSS2, which explains the clinical phenotype described in the vast majority of infected patients that includes pneumonia and diarrhea. Recently, preoccupation about the potential of the virus to infect the skin has been raised by dermatologists due to the increasing observations of cutaneous manifestations in patients with SARS-CoV-2 infection. Although there is little evidence of the expression of ACE2 and TMPRSS2 in the normal skin, the dermatological findings observed among COVID-19 patients warrants further investigation to delineate the mechanisms of skin affection after SARS-CoV-2 infection. Here, we provide a summary of the dermatological findings observed among patients with laboratory-confirmed SARS-CoV-2 infection based on recent reports. In addition, we analyze possible mechanisms of skin injury in COVID-19 patients and discuss about the risk of individuals with chronic skin conditions for SARS-CoV-2 infection. The present review constitutes a useful informative tool to improve our understanding of the pathophysiological mechanisms of COVID-19 and the possible implications of the current pandemic in dermatology.

COVID toes: a unique cutaneous indicator of COVID-19

“…Skin manifestations of COVID-19 patients include erythematous rashes appearing around the onset of symptoms, vesicular eruptions around the trunks and limbs, and urticaria. 17 The appearance of chilblains, or COVID toes, has also been noted. While a definite causative relationship has not been established, one study found that damage to the endothelium by the COVID-19 virus could explain the pathogenesis of COVID toes.…”

“…The Southwest Respiratory and Critical Care Chronicles 2021;9(39): [15][16][17][18][19][20][21] retrospective review of 26 children with COVID toes in Italy in March-April 2020 also demonstrated that all patients recovered without any treatment. 22 In these studies and other published case reports, a variety of treatments have been used.…”

Clinical Manifestations of COVID-19 in the Feet: A Review of Reviews

“…Different authors agree that in children and young adults with suspected COVID-19 infection, reddish purple nodules have been observed on the toes, similar in appearance to pernio erythema or chilblains ("COVID toes") [15][16][17]. They also emphasize that possible dermatological complications are more common and serious in diabetic patients [18]. The distribution of these skin lesions in patients with COVID-19 is mainly located on the torso (66.7%) and the hands and feet (19.4%).…”

“…When the virus infiltrated to the central nervous system it produced neurological pathologies such as encephalitis, ictus, and polyneuropathy [18]. Neurological manifestations in the lower extremities and foot were related to Guillain-Barré syndrome associated with patients with acute symptoms of COVID-19.…”

Toxische epidermale Nekrolyse (TEN) – durch, verstärkt durch oder parallel zu einer SARS-CoV-2-Infektion?

“…Offensichtlich handelt es sich um eine dysregulierte Über-aktivierung von CD8-positiven T-Lymphozyten und NK-Zellen [2], wobei eine genetische Prädisposition bezüglich der HLA-Typen diskutiert wird [3]. Zur Bewertung und Prognoseabschätzung der potenziell lebensbedrohlichen Hauterkrankung wurde der Schweregradscore SCORTEN eingeführt [4].Für die Fachgruppe Dermatologie ist der Zusammenhang von Hauterkrankungen mit einer SARS-CoV-2-Infektion zu Zeiten der Pandemie von großem Interesse und wurde ausführlich diskutiert [5,6]. In Anbetracht fehlender Rezeptorstrukturen (ACE2, TMPRSS2) als Virus-Eintrittspforten darf geschlossen werden, dass die intakte Haut nicht das Target einer Coronavirus-Infektion ist, möglicherweise jedoch die verletzte oder…”