Cutaneous Manifestations in COVID-19: Report on 31 Cases from Five Countries

SIMPLE SUMMARY: This large international registry-based case series contributes to the emerging evidence that skin lesions are one of the important clinical manifestations of COVID-19. Distal ischemic and necrotic lesions, and livedo racemosa usually appears in severe cases and in final disease stages. Pseudochilblains are generally associated with a more benign clinical course. Cutaneous manifestations associated with COVID-19 probably reflect the activation of pathogenic pathways by the virus or a response to inflammatory processes, vascular or systemic complications, or even treatments. Clinical doctors, in general, must be familiar with the cutaneous manifestations of COVID-19 since they may be the only manifestation of the disease in some cases. Early recognition of the cutaneous manifestations of COVID-19 can enable early diagnosis, or guide prognosis and treatment. ABSTRACT: The increasingly frequent cutaneous manifestations of coronavirus disease (COVID-19) remain to pose a problem to clinicians. Herein, we aimed to describe the clinical and pathological findings of skin lesions in patients with COVID-19. The case series, which was based on the International Dermatological Registry circulated to dermatologists worldwide, was conducted across organizations and societies belonging to five different countries. We documented 31 patients with dermatologic manifestations associated with COVID-19, including maculopapular rashes (16.10%), urticarial lesions (26.80%), pseudochilblains (22.60%), petechiae/purpura (6.50%), distal ischaemia and necrosis (6.50%), livedo racemosa (12.90%), and others (9.70%). Twenty-six cases (83.90%) were qRT-PCR-confirmed COVID-19 cases, two (6.50%) were serologically confirmed, while two others (9.7%) were suspected cases owing to previous contact with COVID-19-positive patients. Therefore, our findings indicate that a febrile rash or even a rash in an afebrile state in the early stages of the disease may be the only clinical manifestation of COVID-19. In the future, we recommend close monitoring of all patients with skin lesions not attributable to other causal factors; in the diagnostic perspective, clinicians should aim to confirm if the skin lesions are associated with COVID-19.