Editorial

Covid-19 skin manifestations

0000-0002-6889-5299Vladimir Sánchez Linares^{1  *}  , 0000-0001-5711-3637Laura Nieda Rosales²  , 0000-0003-1570-9058John Jairo Martínez Cuervo² 

¹Policlínico Centro, Sancti Spíritus, Cuba.

²Hospital Provincial General Camilo Cienfuegos de Sancti Spíritus, Cuba.

In December 2019, the first cases of pneumonia of unknown cause were described in Wuhan, China, later identified as secondary to Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2), isolated from lower respiratory tract samples of affected patients, in March 2020 was declared a pandemic by the World Health Organization (WHO). ¹

SARS-CoV-2 infection can occur without any symptoms or with very mild symptoms, the most common are fiber, dry cough and dyspnea; less frequently odynophagia, gastrointestinal symptoms, anosmia or ageusia can occur. A high percentage of patients develop pneumonia, often bilaterally, which can cause respiratory failure symptoms, some require hospital admission and in a smaller percentage in intensive care units. Lethality increases in the elderly, with associated diseases and respiratory signs. ^2,3

Covid-19 can affect different organ systems, including the skin. The first description of skin lesions was made in Italy by Recalcati and other authors, who reported 88 patients of which 18 had skin lesions such as rash erythematosus, urticaria and chickenpox-similar to vesicles. ⁴

The incidence of skin lesions in young patients, often asymptomatic in other organs, is important, especially the pediatric age with clinical variability since skin manifestations may be the only alterations found in children who can transmit the disease in patients at high risk. ⁵

The virus has the capacity to produce 5 independent clinical manifestations: acral lesions of erythema with vesicles or pustules (pseudospits), vesicular, urticarial, maculopapular and livedo lesions and necrosis. It is postulated that the cause is the inflammatory effect of this, which can cause endothelial damage and vascular alterations together with the formation of microthrombi. The diagnosis, given the epidemiological context, is mainly clinical. No relationship has been observed between the magnitude of the cutaneous clinic and the severity of the disease. ^5,6

Erythema-edema of acrylic areas with some vesicles or pustules can resemble chilblains and have purple areas, affect the hands and feet, generally asymmetric, and is observed more in young patients, with a period of 2 weeks, associated with less severe or little symptomatic disease, is accompanied by pain and itching, and appears during the course of the disease. ^6,7

Clinically the lesions consist of macules, papules or often millimetric plaques, delimited in the metatarsophalangeal area, and may involve the whole finger. It often affects only some of the fingers, and in some patients, lesions on the palms and soles. It affects the feet less frequently than the hands, which are initially purple or blue, and can become blisters or crust in their evolution; in some cases, they resemble a multiform erythema or vasculitis; a multiform erythema type subgroup is recognised, with dianiform or atypical target lesions. In studies of patients with these lesions the PCR was negative, the diagnostic support was made by the epidemiological link and the spontaneous resolution of the symptoms. ^7,8 Some authors relate this negativity with the late development of this type of lesions in the context of the disease, the low sensitivity of the tests used or the rapid disappearance of the antibodies. ^8,9

Vesicular eruptions appear early, present on the trunk and extremities, are small monomorphic vesicles (unlike polymorphic vesicles in chickenpox), may have a hemorrhagic content and may become larger or diffuse, with little itching, pain or burning sensation, appear in middle-aged patients, last 10 days and are associated with intermediate severity of the disease. ^7,8

The urticariform lesions become evident more or less parallel to the rest of the general and respiratory symptoms distributed mainly in the trunk and it is frequent the affectation of the face and hands, with resolution in 7 days, its appearance can be associated to a worse prognosis in some patients, it is a non-specific rash, and cases with a favorable course have been described. ^3,7,10

With regard to maculopapular lesions, some show perifollicular distribution and different degrees of desquamation, similar to pityriasis rosea. Purpura may also be present, either punctiform or in larger areas, papules may be observed infiltrating the extremities, mostly on the back of the hands, which look pseudovesicular or similar to erythema elevatum diutinum or erythema multiforme, occasionally pruritic and may appear a few days after the onset of respiratory symptoms or from its onset. ^3,5

The urticariform and maculopapular lesions have a similar pattern, are shorter in duration and usually appear at the same time as the rest of the symptoms and are associated with a more severe disease; itching is common in both. ^3,4

Livedoid or necrotic lesions are relatively uncommon, variable manifestations include transient livedo, appear in elderly patients or patients with associated diseases, are rare and different degrees of lesions observed suggest occlusive vascular disease, including areas of truncal or acral ischemia, other patients show manifestations such as enanthema or purpuric lesions in flection areas, which are considered secondary to a vascular micro-occlusion context and acral ischemia due to the patient´s general deterioration and / or coagulation disorders attributed to Covid-19. ^5,6

Coronavirus can induce a hyperinflammatory syndrome similar to Kawasaki disease; the first report is of a 6-month-old girl with positive PCR for SARS-CoV-2, conjunctivitis, rash, limb swelling and persistent fever; treated with intravenous immunoglobulin and acetyl salicylic acid. Since then, multiple cases have been described with partial or total criteria for Kawasaki disease; among them, two with persistent fever, diarrhea, conjunctivitis, chapped lips, rash, erythema, hand and foot edema, elevated inflammatory markers, lymphopenia, thrombocytopenia and complement intake; both with negative nasal swabs for SARS-CoV-2 and high IgM and IgG titers; suggesting an inflammatory response developed in the later stage of the disease when the virus is no longer detected in the upper respiratory tract. ⁶

Treatment for SARS-CoV-2 can cause toxicodermia such as vasculitis due to antibiotic use, drug reaction with eosinophilia and systemic symptoms and widespread exanthematical pustulosis, the latter two described by the use of hydroxychloroquine. ⁸

Rosacea, eczema, atopic dermatitis and neurodermatitis are frequently aggravated in patients with previous dermatological diseases, and studies have shown a greater number of cases of herpes zoster in patients with Covid-19. ⁸

The differential diagnosis must be made with drug reactions and aggravated dermatological disorders, with diseases causing acroisquemic lesions, such as acrocyanosis, Schönlein-Henoch and other types of vasculitis, including meningococcal sepsis or protein C deficiency, as well as infections caused by other types of viruses. ⁵

The treatment for skin lesions caused by SARS-CoV-2 is according to the patient's symptoms; the application of ice or cold should be avoided since they produce vasoconstriction, corticoids and topical antibiotics are indicated to prevent superinfections in acroisquemic lesions and antihistamines in case of pruritus. The prognosis is generally good, the lesions are self-limited in time and dermatological complications are not considered factors of bad prognosis of the disease. ⁽⁵

In the face of this pandemic with a high lethality, rapid action must be taken, since for the dermatologist and health personnel the description of the cutaneous lesions associated with Covid-19 is significant and they must be careful in their interpretation to evaluate if they are really specific to this virus or secondary to co-infection with other viruses or by toxicodermias.

The dermatological manifestations reported by this lethal virus can be useful to identify possible patients, make an early diagnosis and avoid the transmission and spread of the disease. SARS-CoV-2 has generated changes from all points of view in the world, but medical thinking must always be alert to keep this disease in mind.

REFERENCIAS BIBLIOGRÁFICAS

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2.  Romaní J. La Dermatología española en la era de la COVID-19. Actas Dermosifiliogr [Internet]. 2020 May [citado 5 Sep. 2020]. Disponible en: Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227563/pdf/main.pdf 2.

3.  Carrascosa JM, Morillas V, Bielsa I, Munera-Campos M. Manifestaciones cutáneas en el contexto de la infección por SARS-CoV-2 (COVID-19). Actas dermo-sifiliograficas [Preimpresión]. 2020 Ago. [citado 5 Sep 2020]. Disponible en: Disponible en: https://www.actasdermo.org/es-pdf-S0001731020302878 3.

4.  Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. JEADV [Internet]. 2020 [cited 2020 Ago. 22];34(5):907-1121. Disponible en: Disponible en: https://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.16387 4.

5.  Maqueda-Zamora G, Sierra-Santos L, Sierra-Santos E, Martínez-Ballester JF. Manifestaciones dermatológicas de la infección por Covid-19 en Pediatría. Rev Clin Med Fam [Internet]. 2020 [citado 28 Ago. 2020];13(2):166-70. Disponible en: Disponible en: http://scielo.isciii.es/pdf/albacete/v13n2/1699-695X-albacete-13-02-166.pdf 5.

6.  Arredondo MI, Gómez LV, Del Rio DY. Manifestaciones dermatológicas de COVID-19: ¿casualidad o causalidad?. Rev CES Med [Internet]. 2020 [citado 28 Ago. 2020];34(Esp Covid-19):34-41. Disponible en: Disponible en: https://revistas.ces.edu.co/index.php/medicina/article/view/5625/3185 6.

7.  Torres T, Puig L. Managing cutaneous immune‑mediated diseases during the COVID‑19 pandemic. Am J Clin Dermatol [Internet]. 2020 Apr. [cited 2020 Jul. 22];21(3):307-11. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147535/pdf/40257_2020_Article_514.pdf 7.

8.  Torrelo A. Manifestaciones cutáneas de COVID-19 en niños y adolescentes. Dermatol Venez [Internet]. 2020 [citado 5 Sep. 2020];58(1):5-7. Disponible en: Disponible en: http://revista.svderma.org/index.php/ojs/article/view/1460/1433 8.

9.  Galván Casas C, Català A, Carretero Hernández G, Rodríguez‐Jiménez P, Fernández‐Nieto D, Rodríguez‐Villa Lario A, et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol [Internet]. 2020 [cited 2020 Jul. 22];183(1):71-7. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267236/pdf/BJD-9999-na.pdf 9.

10.  Morey Olivé M, Espiau M, Mercadal Hally M, Lera Carballo E, García Patos V. Manifestaciones cutáneas en contexto del brote actual de enfermedad por coronavirus 2019. An Pediatr (Barc). 2020 Jun [cited 2020 Jul. 22];92(6):374-5. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164857/pdf/main.pdf 10.

Received: September 25, 2020; Accepted: October 19, 2020

^*Autor para la correspondencia. Correo electrónico: [e-mail]

Los autores declaran no tener conflicto de interés en esta investigación.