July 8, 2021

Along with the common symptoms of Covid-19, a few dermatological manifestations have also been reported among a few people affected by the virus. The pathophysiological changes on theirskin leading to different kinds of rashes range from vasculitic changes to formation of microthrombi obliterating the dermal vessels.

Although cutaneous presentations of Covid-19 are infrequent, it is of great importance that all clinicians become aware of these manifestations, as it may help in faster as well as better diagnosis and management of the disease, even among asymptomatic patients. However, they might not be an indicator of the severity of the disease in every case.

Cutaneous rashes appearing before the onset of the typical Covid-19 symptoms are important indicators of this infection. There are skin rashes like maculopapular/morbilliform, urticarial, pityriasis rosea like rash, which appear during the course of the milder form of the disease. Whereas other rashes like acral ischemia, necrosis and hemorrhagic rash appear in patients with critical disease, thus signifying poor prognosis

1) Maculopapular rash(Morbilliform)

Maculopapular rash, with or without pruritus, is the most common cutaneous manifestation of Covid-19, and it is mostly observed during the active phase of the disease.This rash appears in patients belonging comparatively to the younger age group; and is seen late in the course of the disease, and among those affected less severely. These rashes appear predominantly on the trunk of the body as an erythematous rash. These lesions are pruritic and/or painful.

2) Urticaria

Urticarial lesions have been detected more commonly among the elderly.They appear simultaneously with other symptoms of Covid-19. These lesions are seen as erythematous weals associated with itching.

3) Chilblain or Pseudo Chilblains

Pseudo Chilblains have generally been seen among the less-severely affected and the young, and appear late in the course of the disease.These lesions are painful and itchy, and appear as patches of erythematous papules and edema. Vesicles and pustules with purpuric spots have also been detected. Chilblains are painful inflammation of the small blood vessels on the skin, and occur in response to repeated exposure to cold. However, the lesions that appear on the skin of Covid-19 patients are only similar in appearance to chilblains that appear due to exposure to cold, and hence have been termed ‘pseudochilblains’. Moreover, in contrast to other cutaneous manifestations, which appearmostly in the active phase of Covid-19, chilblain often appear in the later phase of the disease, and they appear, usually, on the acral parts of the body, with heels and toes being affected more significantly than fingers.

4) Vesicular lesions, Papulovesicular eruption

These lesions are seen more among middleaged patience. They appear before the onset of other symptoms of Covid-19, and are mostly seen in cases with moderately-severe disease. These lesions appear in the form of papules and vesicles, mainly on the trunk of the body and at times on extremities. They itch. Vesicular lesions, usually manifested like chicken pox, are pruritic papulovesicular rashes that appear mostly on the trunk.

5) Livedo reticularis

The lesions of livedo reticularis appear as reticulate erythematous rash on trunk, thighs and legs. Cutaneous necrosis has also been reported among some patients. They appear among relatively older patients who have been severely affected, and are associated with higher mortality rate. Livedo reticularis is caused by certain conditions, including disseminated intravascular coagulation (DIC), that reduce blood flow through the cutaneous microvasculature system, leading to deoxygenated blood accumulation in the venous plexus. Micro thromboses that manifest in other organs (e.g. cardiopulmonary), and as DIC in critically ill Covid-19 patients, are the most plausible reason for livedo reticularis appearing in such patients.

6) Necrotic-acral ischaemia,

Necrotic-acral ischaemia, haemorrhagic macules and cutaneous necrosis, acral ischemia appearin more severe cases and manifest themselves as gangrenous lesions on toes, possibly because of the hyper-coagulation state in Covid-19 patients. Hemorrhagic rashes have also been found in Covid-19 patients who have been severely affected and with high mortality rate. These appearas small-to-big purpuric lesions.

7) Petechiae

Covid-19 cases have been seen to present signs clinically suggestive of small blood vessel occlusion. And, these can be in the form of petechiae or tiny bruises, transient livedoid eruptions, or acral ischemia, presenting themselves as perniosis-like lesions.

(Dr. Shubha Dhanprakash, MBBS, DDVL (DERMATOLOGY, VENEREOLOGY & LEPROSY), is the Consultant Dermatologist at Indiana Hospital, Mangaluru).

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