The world has changed dramatically since the COVID-19 pandemic began. In addition to our social, occupational, and personal lives, the new coronavirus also poses novel challenges for all physicians, including dermatologists. Several skin conditions have emerged, mainly as a result of prolonged contact with personal protective equipment and excessive personal hygiene. Pressure injury, contact dermatitis, itch, pressure urticaria, and exacerbation of preexisting skin diseases, including seborrheic dermatitis and acne, have been described.
Viral Rash
A rash is a change of the human skin which affects its color, appearance, or texture. Rashes are one of the most common skin problems for adults, children, and babies. Rashes have a variety of causes, including allergies, infections, and certain other diseases. Infectious rashes may be due to bacteria, fungi, or viruses.
Many viruses that cause upper respiratory tract infections also cause rashes in the skin, so it's not surprising that we are seeing these rashes in COVID-19. A viral rash may appear as small bumps, blisters, or patches in various parts of the body. Unlike an allergic reaction, viral rashes usually do not cause itching or pain. Viral rashes usually go away after a few days, but may last up to 2 weeks.
As more people are diagnosed with COVID-19, new and surprising symptoms of the respiratory illness caused by the novel coronavirus keep coming to the surface. First, it was an intense loss of smell and taste. Then, it was gastrointestinal issues like diarrhea. Now, new evidence suggests that patients infected with coronavirus can experience a skin rash, too.
A New Symptom
It has become apparent during the COVID-19 pandemic that it also targets multiple organs, including the skin. A skin rash can sometimes be the only symptom of people infected with COVID-19.
An early report published by dermatologists who worked with 88 coronavirus patients in Italy found that 20% of those people had some kind of skin-related symptom. Of those, half developed a rash when they first started showing signs of the virus, and the other half developed the rash after they were hospitalized.
The three established symptoms of COVID-19, are a high temperature, a new and continuous cough, and a loss or change to your sense of smell or taste. Three types of rashes are identified in the research by King's College London, leading those behind the study to call for skin rashes to be included as a fourth key symptom of COVID-19.
The study said rashes associated with COVID-19 fell into three categories: hive-type rash (urticaria), prickly heat or chickenpox-type rash, COVID fingers and toes (chilblains).
The study - which has been published online two days ago but has not yet been peer-reviewed - drew upon data from the 336,000 regular UK users of the COVID Symptom Study app. With that data, researchers found 8.8% of people who tested positive for the virus suffered a skin rash among their symptoms, compared with 5.4% of those who tested negative.
Similar results were seen in a further 8.2% of users with a rash who did not have a coronavirus test, but still reported the three established COVID-19 symptoms: a cough, fever or loss of smell.
Now the researchers have used data available for 336,847 UK users of the COVID Symptom Study app to investigate the diagnostic value of skin rashes for infection with severe acute respiratory syndrome coronavirus COVID-19.
The team also used data available for 11,546 people who participated in an independent survey on COVID-19-related skin symptoms. Of 27,157 app users who provided swab test results, 2,021 (7.4%) were positive for COVID-19, and 25,136 (92.6%) were negative.
Of the swab-positive inpiduals, 178 (8.8%) reported skin rashes (138 body rashes; 62 acral and 22 both body and acral), compared with 1357 (5.4%) of swab-negative inpiduals.
Skin rashes increased the odds of COVID-19 positivity more than fever. Association analysis showed that the presence of body or acral rashes increased the likelihood of being swab positive for COVID-19 by 67%. This compares with fever increasing the odds of COVID-19 positivity by 47%, and fever is commonly used to screen for COVID. The findings support the inclusion of skin rashes as a suspected symptom.
Among 694 responders who were positive for COVID-19 by swab or antibody test and provided information on COVID-19-related symptoms, the rash appeared before any other symptom in 17% of cases and in 21% of cases, the rash was the only symptom.
COVID-19 Rashes
COVID-19 rashes may present in many forms and at different stages of the disease. The heterogeneous presentations, the time delay, as well as the focus on severely ill patients during the early phases of the pandemic, led to the skin being overlooked as an important target organ for COVID-19.
A Spanish study shows that about 19% of COVID-19 cases may report asymmetrical, chilblain-like lesions around the hands and feet, which could be itchy or painful. The rash may be due to minor thrombotic events or damaged endothelium in small vessels of the digits.
Generally found in younger patients, lasted on average 12 days, appeared later on in the course of the disease, and were associated with mild infections.
About 9% of COVID-19 cases may have outbreaks of small blisters, often itchy, found on the trunk and limbs were found in middle-aged patients, lasted around 10 days, and appeared before other symptoms.
About 19% of COVID-19 cases may report pink or white raised areas of skin that looked liked nettle rash, and often itchy. Mostly on the body but sometimes on the palms of the hands.
About 47% of COVID-19 cases may report maculopapules - small, flat and raised red bumps. They lasted around seven days and appeared at the same time as other symptoms but tended to be seen in patients with more severe infections.
About 6% of COVID-19 cases may report livedo (also known as necrosis) . The skin looked blotchy red or blue, with a net-like pattern. It's a sign of poor blood circulation. This appeared in older patients with severe illness.
One patient in Thailand with a confirmed case of COVID-19 developed a skin rash called petechiae, which are tiny, circular patches that aren’t raised. The patient was originally misdiagnosed with dengue fever, which commonly causes petechiae, only to later be diagnosed with COVID-19.
Importance
Skin manifestations were not prominent features of the SARS and MERS infections ,which makes documenting these in the current COVID-19 infections so important.
It's important that people know that in some cases, a rash may be the first or only symptom of the disease. So if a person notices a new rash, he should take it seriously by self-isolating and getting tested as soon as possible.
By Dr. Magdy Badran
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