Retiform purpura as a dermatological sign of coronavirus disease 2019 (COVID‐19) coagulopathy

Bosch‐Amate, Xavier; Giavedoni, Priscila; Podlipnik, Sebastián; Andreu-Febrer, Cristina; Sanz-Beltran, Judit; García‐Herrera, Adriana; Alós, Llúcia; Mascaró, José M.

doi:10.1111/jdv.16689

Cited by 47 publications

(78 citation statements)

References 11 publications

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“…One of the patients in our series presented concurrent pulmonary embolism and cutaneous intravascular thrombi, whereby DIF showed the deposition of IgM, C3, and fibrinogen within superficial-to-deep dermal blood vessel walls. In addition, C9 deposition was also demonstrated on the vessel walls by IHC [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Skin Manifestations in COVID-19: Prevalence and Relationship with Disease Severity

Giavedoni

Podlipnik

Pericàs

et al. 2020

JCM

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Background: Data on the clinical patterns and histopathology of SARS-CoV-2 related skin lesions, as well as on their relationship with the severity of COVID-19 are limited. Methods and Materials: Retrospective analysis of a prospectively collected cohort of patients with SARS-CoV-2 infection in a teaching hospital in Barcelona, Spain, from 1 April to 1 May 2020. Clinical, microbiological and therapeutic characteristics, clinicopathological patterns of skin lesions, and direct immunofluorescence and immunohistochemical findings in skin biopsies were analyzed. Results: Fifty-eight out of the 2761 patients (2.1%) either consulting to the emergency room or admitted to the hospital for COVID-19 suspicion during the study period presented COVID-19 related skin lesions. Cutaneous lesions could be categorized into six patterns represented by the acronym “GROUCH”: Generalized maculo-papular (20.7%), Grover’s disease and other papulo-vesicular eruptions (13.8%), livedo Reticularis (6.9%), Other eruptions (22.4%), Urticarial (6.9%), and CHilblain-like (29.3%). Skin biopsies were performed in 72.4%, including direct immunofluorescence in 71.4% and immunohistochemistry in 28.6%. Patients with chilblain-like lesions exhibited a characteristic histology and were significantly younger and presented lower rates of systemic symptoms, radiological lung infiltrates and analytical abnormalities, and hospital and ICU admission compared to the rest of patients. Conclusion: Cutaneous lesions in patients with COVID-19 appear to be relatively rare and varied. Patients with chilblain-like lesions have a characteristic clinicopathological pattern and a less severe presentation of COVID-19.

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Section: Discussionmentioning

confidence: 99%

Skin Manifestations in COVID-19: Prevalence and Relationship with Disease Severity

Giavedoni

Podlipnik

Pericàs

et al. 2020

JCM

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“…Bosch-Amate et al [32] Thrombogenic vasculopathy; extensive necrosis of epidermis and adnexal structures; interstitial and perivascular neutrophilia with leukocytoclasia; extensive deposition of C5b-9 in microvasculature Magro et al [6] Livedo reticularis or racemosa (Table 2). A report of erythema multiforme major with mucosal involvement also exists [58].…”

Section: Maculopapular Exanthemsmentioning

confidence: 99%

“…Published findings from the AAD COVID-19 Registry noted that all patients with retiform purpura were hospitalized and 82% had ARDS due to SARS-CoV-2 [13••]. Painful, retiform purpura with hemorrhagic blistering and evidence of small vessel thrombi and complement activation was observed in the setting of progressive thrombocytopenia with acute SARS-CoV-2 infection [32]. Retiform purpura with concomitant acral livedo racemosa has also been noted [31].…”

Section: Retiform Purpuramentioning

confidence: 99%

“…Retiform purpura with concomitant acral livedo racemosa has also been noted [31]. Histopathology shows complement deposits suggesting complement pathway activation involved in coagulopathic-driven thrombi (Table 2) [31,32]. Furthermore, Magro et al demonstrated pauciinflammatory vascular thrombosis with extensive complement deposits and detection of SARS-CoV-2 protein localized to endothelial cells [35,74].…”

Section: Retiform Purpuramentioning

confidence: 99%

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Cutaneous Manifestations in Adult Patients with COVID-19 and Dermatologic Conditions Related to the COVID-19 Pandemic in Health Care Workers

Mawhirt

Frankel

Diaz³

2020

Curr Allergy Asthma Rep

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Purpose of Review COVID-19 (coronavirus viral disease 2019), due to the novel SARS-CoV-2, may present with different types of cutaneous manifestations of varying pathophysiology. During the ongoing pandemic, publications reporting dermatologic findings in COVID-19 continue to emerge. Recent Findings Cutaneous vasculopathy and microthrombus-related changes including acral and sacral lesions, retiform purpura, livedo reticularis, and cutaneous vasculitis are notable findings in adult patients. Other exanthems include urticaria or angioedema, morbilliform/maculopapular exanthems, erythema multiforme, and vesicular eruptions. Increased recognition of these findings, especially those consistent with cutaneous microthrombi or vasculitis, is of particular importance. Additionally, occupational dermatologic disease related to extended personal protective equipment (PPE) use, such as skin damage and irritant or allergic contact dermatitis (ACD), represents another emerging problem amidst the pandemic. Summary In this review, we highlight the various cutaneous manifestations associated with COVID-19 in adult patients and occupational dermatitis in health care workers (HCWs) caring for this patient population. Keywords COVID-19. SARS-CoV-2. Cutaneous manifestations. Dermatologic. Rash. Contact dermatitis Abbreviations AAD American Academy of Dermatology ACD Allergic contact dermatitis ACE2 Angiotensin-converting enzyme 2 AD Atopic dermatitis AGEP Acute generalized exanthematous pustulosis ARDS Acute respiratory distress syndrome COVID-19 Coronarvirus viral disease 2019 CSSV Cutaneous small vessel vasculitis DIC Disseminated intravascular coagulation DiHS/DRESS Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms HCW Health care worker ICD Irritant contact dermatitis ITP Immune thrombocytopenic purpura PPE Personal protective equipment PT Patch test RT-PCR Reverse transcriptase polymerase chain reaction SARS-CoV-2 Severe acute respiratory distress syndrome coronavirus 2 SDRIFE Symmetrical drug-related intertriginous and flexural exanthema This article is part of the Topical Collection on Allergic Skin Diseases

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“…Analysis of skin samples from patients with distinct COVID‐19 skin lesions may help establish the pathophysiology of cutaneous involvement, which appears to be less frequent than manifestations of the virus in other organs and tissues. A literature search in PubMed using the key terms “skin and COVID‐19” or “cutaneous and COVID‐19” identified descriptions of cutaneous manifestations in 89 articles, [ 3‐47] and almost 1150 patients registered with a variety of cutaneous lesions.…”

Section: Introductionmentioning

confidence: 99%

Potential interactions of SARS‐CoV‐2 with human cell receptors in the skin: Understanding the enigma for a lower frequency of skin lesions compared to other tissues

Criado

Pincelli

Criado

et al. 2020

Experimental Dermatology

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The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) represents a new public health problem, with a total of 10.577.263 documented COVID‐19 cases worldwide and 513.441 deaths up to the present date. Few cases of disease‐related cutaneous manifestations have been reported in the literature, and such manifestations are scarce. Integumentary manifestations from COVID‐19 include exanthemas and papular dermatoses, urticarial eruptions, atopic dermatitis, vesiculobullous lesions and skin signs of hypercoagulable states, such as acral ischaemia, livedo and retiform purpura. Most common extracutaneous manifestations from the disease include headache, cough, anosmia, ageusia, fever, dyspnoea, nausea, diarrhoea and cardiovascular events. The objectives of this review were to discuss the role of human cell receptors described as interaction targets of SARS‐CoV‐2, as well to understand the current state of knowledge on skin expression of these receptors, in order to substantiate future research. The authors present a thorough literature review on SARS‐CoV‐2 and its possible interaction with cell receptors and human tissues including the skin. They discuss a molecular hypothesis to explain the lower prevalence of dermatological manifestations from direct SARS‐CoV‐2 infection. Distinct human cell receptors binding the virus appear to be less expressed in the skin compared to other organs. Additionally, the presence of resolvins and the disintegrin metalloprotease ADAM17 provide a putative protection to the skin, explaining the majority of COVID‐19 manifestations to be extracutaneous. This review represents an excellent opportunity for future studies using skin biopsies from COVID‐19 patients to investigate molecular expression in the pathophysiology of cutaneous manifestations of the disease.

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Retiform purpura as a dermatological sign of coronavirus disease 2019 (COVID‐19) coagulopathy

Abstract: Letter to the Editor COVID-19 infection in the differential diagnosis of retiform purpura. 10

Cited by 47 publications

References 11 publications

Skin Manifestations in COVID-19: Prevalence and Relationship with Disease Severity

Skin Manifestations in COVID-19: Prevalence and Relationship with Disease Severity

Cutaneous Manifestations in Adult Patients with COVID-19 and Dermatologic Conditions Related to the COVID-19 Pandemic in Health Care Workers

Potential interactions of SARS‐CoV‐2 with human cell receptors in the skin: Understanding the enigma for a lower frequency of skin lesions compared to other tissues

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