Classification of the cutaneous manifestations of Covid-19: a rapid prospective nationwide consensus study in Spain with 375 cases.
British J Dermatol 29 April 2020 https://doi.org/10.1111/bjd.19163
Reviewed by Dr Melissa Tan, National Skin Centre
Català, Carretero Hernández and colleagues carried out a nationwide case collection survey of images and clinical data amongst all Spanish dermatologists. Patients with a recent acute skin eruption of no clear aetiology and suspected or confirmed Covid-19 were included. Four dermatologists independently reviewed the photographs to reach a consensus on the cutaneous patterns of disease.
Five major cutaneous clinical patterns of Covid-19 were found in this study comprising 375 patients.
1) Acral areas of erythema-oedema with some vesicles or pustules (pseudo-chilblain) (19% of cases). These lesions may resemble chilblains with purpuric areas, affecting hands and feet, may be painful or itchy and were usually asymmetrical. The patients with these lesions were younger and this clinical pattern was associated with less severe disease.
2) Other vesicular eruptions (9%). Small monomorphic vesicles were noted on the trunk whilst larger or diffuse vesicles with haemorrhagic content were seen on the limbs. This clinical pattern affected middle aged patients and was associated with intermediate severity.
3) Urticarial lesions (19%). These were very itchy and were mostly on the trunk or diffuse with a few palmar cases. They were associated with more severe COVID-19 disease with a 2% mortality in this cohort.
4) Other maculopapular eruptions (47%). These may have perifollicular distribution and varying degrees of scaling with some described as similar to pityriasis rosea. Purpura may
also be present, either punctiform or on larger areas. A few patients had infiltrated papules on their extremities, mostly dorsum of the hands, with pseudovesicular appearance or resembled erythema elevatum diutinum or erythema multiforme. Similar to urticarial lesions, maculopapular eruptions were associated with more severe COVID-19 disease with a 2% mortality in this cohort.
5) Livedo or necrosis (6%). These patients showed varied extent of lesions that were suggestive of occlusive vascular disease, including areas of truncal or acral ischemia. Most were older patients with more severe disease (10% mortality) though some patients had transient livedo and did not require hospitalization.
Severity of disease was determined by presence of pneumonia, admission, and intensive care requirements. Pseudo-chilblain was associated with less severe disease while livedoid presentations was associated with most severe disease. All skin lesions lasted less than 2 weeks.
A few patients had other manifestations such as enanthem or purpuric flexural lesions. There may also be an increased number of herpes zoster cases in COVID-19 patients.
The strengths of this study are the large study size and systematic classification of clinical patterns into broad categories. However, as the authors noted, patients with severe disease were omitted in the study due to difficulty in obtaining consent. Similarly, mild disease in the general population may be underrepresented though this may be slightly mitigated by the inclusion of not only confirmed cases but also suspected cases.
The authors opined that pseudo-chilblain and vesicular lesions may be the most useful as indicators of disease. Pseudo-chilblain lesions more commonly appear later during the disease and were not associated with severe disease. Subtypes of maculopapular lesions resembling erythema elevatum diutinum or erythema multiforme could lead to suspected Covid-19 diagnosis. Livedoid/necrotic lesions occurred late and are probably unhelpful for diagnosis but fits with the idea of COVID-19 vascular damage. Most urticarial lesions were non-specific.