COVID-19: An Overview of SARS-CoV-2 Variants-The Current Vaccines and Drug Development

The world is presently in crisis facing an outbreak of a health-threatening microorganism known as COVID-19, responsible for causing uncommon viral pneumonia in humans. The virus was first reported in Wuhan, China, in early December 2019, and it quickly became a global concern due to the pandemic. Challenges in this regard have been compounded by the emergence of several variants such as B.1.1.7, B.1.351, P1, and B.1.617, which show an increase in transmission power and resistance to therapies and vaccines. Ongoing researches are focused on developing and manufacturing standard treatment strategies and effective vaccines to control the pandemic. Despite developing several vaccines such as Pfizer/BioNTech and Moderna approved by the U.S. Food and Drug Administration (FDA) and other vaccines in phase 4 clinical trials, preventive measures are mandatory to control the COVID-19 pandemic. In this review, based on the latest findings, we will discuss different types of drugs as therapeutic options and confirmed or developing vaccine candidates against SARS-CoV-2. We also discuss in detail the challenges posed by the variants and their effect on therapeutic and preventive interventions.

SARS-CoV-2 Infection and Vaccination Cutaneous Manifestations for the Inpatient Dermatologist

Purpose of Review

The overall purpose of this review was to characterize and summarize cutaneous eruptions associated with coronavirus disease 2019 (COVID-19) as well as COVID-19 vaccination.

Recent Findings

Cutaneous eruptions associated with COVID-19 infection have a reported frequency of 1-20%. Increased COVID-19 disease severity has been associated with morbilliform exanthems, urticaria, retiform purpura, and livedo racemosa. Papulovesicular eruptions were associated with a milder COVID-19 disease course. A range of dermatoses have also been reported with COVID-19 vaccination but have rarely prevented subsequent vaccination.

Summary

Dermatologists should be aware of the associations between COVID-19 disease severity and cutaneous eruptions. Livedo racemosa and retiform purpura are particularly associated with increased disease severity and death. In the setting of COVID-19 vaccination, cutaneous eruptions can largely be managed symptomatically and very rarely do these reactions prevent subsequent vaccination.

Histopathological and Immunohistochemical Characterization of Skin Biopsies From 41 SARS-CoV-2 (+) Patients: Experience in a Mexican Concentration Institute: A Case Series and Literature Review

ABSTRACT

The SARS-CoV-2 pandemic brought countless clinical and pathophysiological questions. Although mucocutaneous infections are the most visible, they are among the least studied. This article provides relevant information to characterize morphologically and immunohistochemically the dermatoses from patients with COVID-19, during the first year of the pandemic. Immunohistochemistry reactions against the spike protein were performed in 48 skin biopsies, and the positive cases were classified according to their histomorphology; at the end, 41 biopsies led us to identify 12 morphological patterns that mimic other skin pathologies, among which pityriasiform patterns predominate. For the literature review, we selected cases of SARS-CoV-2 dermatoses that included complete histopathological information and that were published during the same interval of time; after careful evaluation, 205 biopsies were selected and then classified into 8 groups according to previously published proposals. Dermatoses associated with SARS-CoV-2 are as diverse in their clinical expression as in their histopathology, mimicking entities totally unrelated to COVID-19. Furthermore, some of these groups are characteristically associated with an aggressive course of the disease. Undoubtedly, it is necessary to delve into the possibility that these findings are translatable into prognostic and therapeutic factors.

Symptom Clustering Patterns and Population Characteristics of COVID-19 Based on Text Clustering Method

Background

Descriptions of single clinical symptoms of coronavirus disease 2019 (COVID-19) have been widely reported. However, evidence of symptoms associations was still limited. We sought to explore the potential symptom clustering patterns and high-frequency symptom combinations of COVID-19 to enhance the understanding of people of this disease.

Methods

In this retrospective cohort study, a total of 1,067 COVID-19 cases were enrolled. Symptom clustering patterns were first explored by a text clustering method. Then, a multinomial logistic regression was applied to reveal the population characteristics of different symptom groups. In addition, time intervals between symptoms onset and the first visit were analyzed to consider the effect of time interval extension on the progression of symptoms.

Results

Based on text clustering, the symptoms were summarized into four groups. Group 1: no-obvious symptoms; Group 2: mainly fever and/or dry cough; Group 3: mainly upper respiratory tract infection symptoms; Group 4: mainly cardiopulmonary, systemic, and/or gastrointestinal symptoms. Apart from Group 1 with no obvious symptoms, the most frequent symptom combinations were fever only (64 cases, 47.8%), followed by dry cough only (42 cases, 31.3%) in Group 2; expectoration only (21 cases, 19.8%), followed by expectoration complicated with fever (10 cases, 9.4%) in Group 3; fatigue complicated with fever (12 cases, 4.2%), followed by headache complicated with fever was also high (11 cases, 3.8%) in Group 4. People aged 45–64 years were more likely to have symptoms of Group 4 than those aged 65 years or older (odds ratio [OR] = 2.66, 95% CI: 1.21–5.85) and at the same time had longer time intervals.

Conclusions

Symptoms of COVID-19 could be divided into four clustering groups with different symptom combinations. The Group 4 symptoms (i.e., mainly cardiopulmonary, systemic, and/or gastrointestinal symptoms) happened more frequently in COVID-19 than in influenza. This distinction could help deepen the understanding of this disease. The middle-aged people have a longer time interval for medical visit and was a group that deserve more attention, from the perspective of medical delays.

CUTANEOUS MANIFESTATIONS OF COVID-19 IN A TERTIARY COVID REFERRAL HOSPITAL IN THE PHILIPPINES

Background

Reports on COVID-19 skin manifestations and associated clinical outcomes are limited. Like viral diseases, cutaneous findings may be present and can help in confirmation and prognostication among those suspected or diagnosed with COVID-19.

Objective

To determine COVID-19 cutaneous manifestations and their association with disease severity and course.

Methods

This study was conducted in a designated COVID-19 referral hospital from January 1 to March 31, 2021. Skin manifestations recorded from January 1 to February 17 were retrospectively gathered. Reports from February 18 to March 31 were prospectively collected using a dermatologic checklist which was incorporated into all official medical records.

Results

A total of 507 confirmed patients with COVID-19 were included. COVID-19 skin signs were detected in 39 patients (7.7%). Morbilliform lesions were most common. Skin signs were significantly associated with severe or critical cases (odds ratio, 3.4; 95% CI, 1.3-8.7) and mortality (relative risk, 2.9; 95% CI, 2.0-4.2).

Limitations

Underestimation of prevalence of COVID-19 skin signs due to exclusion of outpatient and discharged patients and the subjective assessment in the retrospective part.

Conclusion

Cutaneous signs were significantly associated with severe/critical COVID-19 as well as death among 507 hospitalized patients in a Philippine COVID-19 referral hospital.

Cutaneous manifestation of COVID-19: What have we learned an year into the pandemic?

Coronavirus disease-19 (COVID-19) is an emerging health situation caused by the "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). The ongoing COVID-19 pandemic which emerged from the Chinese city of Wuhan in December 2019 has spread to over 188 countries and infected over 100 million people across the globe in over one year. Most common symptoms of COVID-19 include fever and respiratory illness. Among extrapulmonary signs associated with COVID-19, dermatological manifestations have been increasingly reported from different geographical regions. The exact incidence or prevalence of COVID-19 associated skin manifestation remains largely unknown and the pathophysiological mechanisms are still unclear. In this article, we have attempted to give a comprehensive overview of what has been learned an year into the pandemic on the epidemiology, clinical and histopathological features, pathophysiological mechanisms and clinical management of COVID-19 associated cutaneous manifestations.

Drug-based therapeutic strategies for COVID-19-infected patients and their challenges

Emerging epidemic-prone diseases have introduced numerous health and economic challenges in recent years. Given current knowledge of COVID-19, herd immunity through vaccines alone is unlikely. In addition, vaccination of the global population is an ongoing challenge. Besides, the questions regarding the prevalence and the timing of immunization are still under investigation. Therefore, medical treatment remains essential in the management of COVID-19. Herein, recent advances from beginning observations of COVID-19 outbreak to an understanding of the essential factors contributing to the spread and transmission of COVID-19 and its treatment are reviewed. Furthermore, an in-depth discussion on the epidemiological aspects, clinical symptoms and most efficient medical treatment strategies to mitigate the mortality and spread rates of COVID-19 is presented.

Cutaneous manifestation of COVID-19: What have we learned an year into the pandemic?

Coronavirus disease-19 (COVID-19) is an emerging health situation caused by the "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). The ongoing COVID-19 pandemic which emerged from the Chinese city of Wuhan in December 2019 has spread to over 188 countries and infected over 100 million people across the globe in over one year. Most common symptoms of COVID-19 include fever and respiratory illness. Among extrapulmonary signs associated with COVID-19, dermatological manifestations have been increasingly reported from different geographical regions. The exact incidence or prevalence of COVID-19 associated skin manifestation remains largely unknown and the pathophysiological mechanisms are still unclear. In this article, we have attempted to give a comprehensive overview of what has been learned an year into the pandemic on the epidemiology, clinical and histopathological features, pathophysiological mechanisms and clinical management of COVID-19 associated cutaneous manifestations.

WIN 55,212-2 shows anti-inflammatory and survival properties in human iPSC-derived cardiomyocytes infected with SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which can infect several organs, especially impacting respiratory capacity. Among the extrapulmonary manifestations of COVID-19 is myocardial injury, which is associated with a high risk of mortality. Myocardial injury, caused directly or indirectly by SARS-CoV-2 infection, can be triggered by inflammatory processes that lead to damage to the heart tissue. Since one of the hallmarks of severe COVID-19 is the "cytokine storm", strategies to control inflammation caused by SARS-CoV-2 infection have been considered. Cannabinoids are known to have anti-inflammatory properties by negatively modulating the release of pro-inflammatory cytokines. Herein, we investigated the effects of the cannabinoid agonist WIN 55,212-2 (WIN) in human iPSC-derived cardiomyocytes (hiPSC-CMs) infected with SARS-CoV-2. WIN did not modify angiotensin-converting enzyme II protein levels, nor reduced viral infection and replication in hiPSC-CMs. On the other hand, WIN reduced the levels of interleukins six, eight, 18 and tumor necrosis factor-alpha (TNF-α) released by infected cells, and attenuated cytotoxic damage measured by the release of lactate dehydrogenase (LDH). Our findings suggest that cannabinoids should be further explored as a complementary therapeutic tool for reducing inflammation in COVID-19 patients.

[Cutaneous Manifestation of COVID-19: What have we learned an year into the pandemic?]

La enfermedad por coronavirus de 2019 (COVID-19) es una situación sanitaria emergente causada por el «síndrome respiratorio agudo severo por coronavirus 2» (SARS-CoV-2). La pandemia por COVID-19 en curso, que surgió de la ciudad china de Wuhan en diciembre de 2019, se ha propagado en 188 países, y ha infectado a más de 100 millones de personas a nivel mundial a lo largo de un año. Los síntomas más comunes de la COVID-19 incluyen fiebre y enfermedad respiratoria. Entre los signos extrapulmonares asociados a COVID-19 se han reportado cada vez más manifestaciones dermatológicas en las diferentes regiones geográficas. La incidencia o prevalencia exactas de las manifestaciones cutáneas asociadas a la COVID-19 son bastante desconocidas, y los mecanismos patofisiológicos siguen sin dilucidarse. En este artículo hemos tratado de aportar una visión general amplia de lo que hemos aprendido en un año de inmersión en la pandemia en cuanto a epidemiología y características clínicas e histopatológicas, mecanismos patofisiológicos y manejo clínico de las manifestaciones cutáneas asociadas a la COVID-19.

Oral and cutaneous manifestations of viral and bacterial infections: Not only COVID-19 disease

Globalization entails several medical problems along with economic and social complications. Migrations from other continents, increasing numbers of tourists worldwide, and importation of foreign parasites (eg, Aedes albopictus) have made diseases previously unknown in Europe a reality. The rapid spread of the coronavirus disease 2019 pandemic throughout the world is a warning that other epidemics are still possible. Most, if not all of these diseases, transmitted by viruses or bacteria, present with cutaneous symptoms and signs that are highly important for a speedy diagnosis, a fundamental concept for arresting the diseases and saving lives. Dermatologists play a significant role in delineating cutaneous and mucosal lesions that are often lumped together as dermatitis. We provide a review of many of these cutaneous and mucosal lesions that sometimes are forgotten or even ignored.

Synthesis of the Data on COVID-19 Skin Manifestations: Underlying Mechanisms and Potential Outcomes

The incidence of coronavirus disease 2019 (COVID-19)-related skin manifestations has progressively grown, in parallel with the global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreading. The available evidence indicates that cutaneous signs are heterogeneous and can be divided as follows: a) erythematous rashes, b) lesions of vascular origin, c) vesicular rashes, d) urticarial rashes, and e) acute generalized exanthematous pustulosis (AGEP), erythema multiforme (EM) and other polymorphic/atypical reactions. Most cutaneous manifestations appear simultaneously or after respiratory and/or systemic symptoms such as fever, even if rarely urticaria has been reported as the first sign of the disease. It has been proposed that erythematous and vesicular rashes, as well as urticaria, are the result of immunological activation against Sars-CoV-2, similarly to other viral exanthems; alternatively, reactivation or co-infection of herpesviruses and drug hypersensitivity represent possible etiologic diagnosis that has to be considered. Regarding lesions of vascular origin, ischemic ones are the result of systemic hypercoagulability established in severe infections, whereas chilblains seem to be linked to the type I-interferon massively produced to halt virus replication. AGEP is triggered by drugs, whereas EM could represent a delayed immune response to the virus or a hypersensitivity reaction to drugs elicited by the inflammatory process built to fight the infection. A further pathogenic hypothesis is that the virus, or its particles detected in the skin (particularly in endothelium and eccrine glands), could be responsible for certain skin reactions, including chilblains and EM. From the available data, it appears that chilblains are correlated with younger age and less severe disease, while ischemic manifestations occur in the elderly with severe infection. In conclusion, larger studies are needed to confirm the suggested pathogenetic mechanisms of COVID-19-related skin reactions and to determine the potential prognostic significance of each one.

Not all that glitters is COVID-19: a case series demonstrating the need for histopathology when skin findings accompany SARS-CoV-2 infection

BACKGROUND

Descriptions of cutaneous findings associated with COVID-19 have not been consistently accompanied by histopathology or confirmatory testing for SARS-CoV-2.

OBJECTIVE

To describe and classify the cutaneous findings with supporting histopathology of confirmed COVID-19 inpatients.

METHODS

We included consecutive inpatients with a confirmed diagnosis of COVID-19 for whom a dermatology consult was requested. A skin biopsy was performed in all cases. Skin findings were classified as being compatible with a cutaneous manifestation of COVID-19 or as representing a distinct clinical entity.

RESULTS

Twenty-eight patients were studied in whom thirty-one dermatologic diagnoses were made. Twenty-two of the dermatoses were compatible with a cutaneous manifestation of COVID-19; nine entities were not associated with infection by SARS-CoV-2. The most common COVID-19-associated pattern was an exanthematous presentation. In four patients, a new pattern was observed, characterized by discrete papules with varied histopathological findings including a case of neutrophilic eccrine hidradenitis. No cases of pernio-like lesions were identified. Skin findings not associated with COVID-19 represented 29% of diagnoses and included Malassezia folliculitis, tinea, miliaria and contact dermatitis.

LIMITATIONS

There is no gold-standard test to distinguish between viral exanthems and drug reactions.

CONCLUSION

A histopathological study is critical before attributing skin findings to a manifestation of COVID-19.

Skin disorders associated with the COVID-19 pandemic: A review

Introduction

In December 2019, a new coronavirus has emerged out of China, the SARS‐CoV‐2 virus, causing a disease known as COVID‐19, which steadily has progressed into a pandemic. This coronavirus affects many organs, including the skin, whose manifestations are a consequence of the disease itself, as well as the preventative measures taken to avoid the infection. This paper reviews the cutaneous manifestations which currently have been encountered during this pandemic.

Methods

A search was conducted on PubMed, and all relevant articles were included.

Results

The results show the occurrence of many cutaneous findings, ranging from those related to the infection itself and to various dermatitides related to the use of personal protective equipment (PPE) utilized by healthcare workers while attending to infected patients.

Discussion

Recognizing these findings is important for the accurate diagnosis of those infected with COVID‐19 as well as the prompt treatment of the side effects caused by PPE that might further impair the effectiveness of healthcare workers.

A systematic review of dermatologic manifestations among adult patients with COVID-19 diagnosis

BACKGROUND

Infection with COVID-19 is characterized by respiratory, gastrointestinal and neurologic symptoms. However, limited evidence exists of the involvement of the integumentary system among COVID-19 patients and evidence suggests that these symptoms may even be the first presenting sign.

OBJECTIVE

To systematically evaluate the literature published on dermatologic signs of COVID-19 in order to educate doctors about the dermatologic signs of COVID-19 infection.

METHODS

Lit COVID, World Health Organization COVID-19 database and PubMed were searched using terminology to identify adult patients with confirmed COVID-19 infection and dermatologic manifestations of disease. The last search was completed on 13 July 2020.

RESULTS

There were 802 reports found. After exclusion, 20 articles were found with 347 patients with confirmed COVID-19 infection. Within these articles, 27 different skin signs were reported.

LIMITATIONS

Limitations of this review include the recency of COVID-19 infection; so, there are limited published reports and that many reports are not by dermatologists, and so, the cutaneous signs may be misdiagnosed or misdescribed.

CONCLUSION

Dermatologic manifestations of COVID-19 may be the first presenting sign of infection; so, dermatologists and doctors examining the skin should be aware of the virus's influence on the integumentary system in order to promptly diagnose and treat the infected patients.

Time of Onset of Selected Skin Lesions Associated with COVID-19: A Systematic Review

INTRODUCTION

Distinct skin lesions associated with coronavirus disease 2019 (COVID-19) have been described, but data regarding their time of onset during the COVID-19 course are scant. Our objective was to systematically review the studies reporting the time of onset of selected skin lesions with respect to the reported onset of the COVID-19 core symptoms.

METHODS

A comprehensive search of studies published before 21 January 2021 was performed on MEDLINE via PubMed database using a predefined strategy to identify relevant articles.

RESULTS

Out of 354 references, 87 were selected, reporting a total of 895 patients with skin lesions associated with COVID-19. The most frequent pattern was exanthema (n = 430, 48%), followed by vascular (n = 299, 33%), urticarial (n = 105, 12%) and others (n = 66, 7%). Skin lesions occurred more frequently in the first 4 weeks from the COVID-19 onset (n = 831, 92%), whereas prodromal or late lesions were rarer (n = 69, 8%). The urticarial and exanthema patterns were more frequent in the first 2 weeks. About the vascular pattern some differences were noted among its subtypes. Livedoid lesions occurred mainly in the first 2 weeks, while chilblain-like lesions between weeks 2 and 4. Purpuric/petechial lesions were equally distributed during the first 4 weeks. Several skin manifestations did not fall into the pattern classification, including erythema multiforme, generalized pruritus, Kawasaki disease and others.

CONCLUSION

The diversity in the time of onset of skin lesions as well as their polymorphic nature likely reflects the diversity of the pathogenetic underlying mechanisms.

PROSPERO DATABASE REGISTRATION NUMBER

CRD42021236331.

A systematic review of the histopathologic survey on skin biopsies in patients with Corona Virus Disease 2019 (COVID-19) who developed virus or drug-related mucocutaneous manifestations

The mucocutaneous manifestations of Corona Virus Disease 2019 (COVID‐19) logically may reflect systemic visceral involvements. These findings are visible and easy to approach like biopsies for exact histopathologic evaluations. This systematic review was conducted to collect the mucocutaneous histopathologic data of COVID‐19 patients for future investigations and interpretations. The COVID‐19 dermatology resource of the Centre of Evidence‐Based Dermatology (CEBD) at the University of Nottingham, PubMed, Scopus, Google Scholar and Medscape was searched for relevant English articles published by June 3, 2020. This review included 31 articles, involving 459 patients. The common primary virus‐related mucocutaneous manifestations are easy to approach in the course of COVID‐19. The authors of this study supposed dermatopathological findings as the predictors of the nature of potential systemic involvements and outcomes of COVID‐19. Scrutinizing these findings can help with adopting more effective therapeutic and management strategies; nevertheless, this review found the severity and time of onset of symptoms not to be associated with the laboratory and histopathological findings. Deterioration of clinical conditions and laboratory tests was also not related to the histopathological findings. It is recommended that meta‐analyses be conducted in the future to detail on these data for having more comprehensive and better conclusion.

Skin manifestations in COVID-19 patients, state of the art. A systematic review

INTRODUCTION

Since COVID-19 has become a pandemic, extensive literature has been produced. The commonest symptoms of COVID-19 disease are fever, cough, anosmia, and lymphocytopenia. However, other apparently less common clinical symptoms have been described, including skin lesions. We conducted a systematic review to evaluate skin involvement in COVID-19.

METHODS

The authors performed a systematic review of literature, in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA). The search was reiterated until May 06, 2020.

RESULTS

Overall, 1593 patients (M/F ratio: 1 : 9) with suspect of COVID-19 were examined. The mean age was 37.8 (range 0-91) years. Among the analyzed patients, 84 (5.3%) were pediatrics (<18 years). Chilblains are very common among skin lesions and represent almost half of all skin lesions reported (46%); in 75% of patients with cutaneous manifestation, the latter presented before other typical clinical manifestation of COVID-19. Vasculitis or thrombosis was identified in almost 70% of patients who suffered from skin manifestations.

CONCLUSION

The present study highlights the importance of skin involvement in COVID-19. Limbs should be examined to eventually foresee the onset of further typical symptoms. Chilblains can be considered typical features. Studies with higher scientific evidence are required.

Skin manifestations of COVID-19 in children: Part 2

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults, as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discussed one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions. In this part of the review, we describe other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Associations between COVID-19 and skin conditions identified through epidemiology and genomic studies

BACKGROUND

Coronavirus disease 2019 (COVID-19) is commonly associated with skin manifestations, and may also exacerbate existing skin diseases, yet the relationship between COVID-19 and skin diseases remains unclear.

OBJECTIVE

By investigating this relationship through a multiomics approach, we sought to ascertain whether patients with skin conditions are more susceptible to COVID-19.

METHODS

We conducted an epidemiological study and then compared gene expression across 9 different inflammatory skin conditions and severe acute respiratory syndrome coronavirus 2-infected bronchial epithelial cell lines, and then performed a genome-wide association study transdisease meta-analysis between COVID-19 susceptibility and 2 skin diseases (psoriasis and atopic dermatitis).

RESULTS

Skin conditions, including psoriasis and atopic dermatitis, increase the risk of COVID-19 (odds ratio, 1.55; P = 1.4 × 10-9) but decrease the risk of mechanical ventilation (odds ratio, 0.22; P = 8.5 × 10-5). We observed significant overlap in gene expression between the infected normal bronchial epithelial cells and inflammatory skin diseases, such as psoriasis and atopic dermatitis. For genes that are commonly induced in both the severe acute respiratory syndrome coronavirus 2 infection and skin diseases, there are 4 S100 family members located in the epidermal differentiation complex, and we also identified the "IL-17 signaling pathway" (P = 4.9 × 10-77) as one of the most significantly enriched pathways. Furthermore, a shared genome-wide significant locus in the epidermal differentiation complex was identified between psoriasis and severe acute respiratory syndrome coronavirus 2 infection, with the lead marker being a significant expression quantitative trait locus for S100A12 (P = 3.3 × 10-7).

CONCLUSIONS

Together our findings suggest association between inflammatory skin conditions and higher risk of COVID-19, but with less severe course, and highlight shared components involved in anti-COVID-19 immune response.

Maculopapular skin eruptions associated with Covid-19: A systematic review

In this systematic review, we anticipated in summarizing clinical features, histopathological hallmarks, and possible pathology behind the maculopapular skin eruptions occurring in Covid-19 patients. A literature search was executed using MEDLINE/PubMed and Embase databases for articles published till 20 November 2020. All eligible articles including observational studies, case reports, and case series reporting the maculopapular skin lesion in Covid-19 patients were included. Data were obtained for 354 Covid-19 patients presenting with maculopapular lesions from 40 studies. The mean age of these patients was 53 years, and with 42% of them being male. These maculopapular lesions differed considerably in terms of distribution and appearance, ranging from diffuse erythematous maculopapular lesions to scattered erythematous macules coalescing into papules to maculopapular lesions in plaques. The mean duration of the lesion was 8 days. These lesions were frequently localized on trunks and extremities. Superficial perivascular dermatitis with lymphocytic infiltrate was a histopathological hallmark of these lesions. As these skin lesions may have a possible association with diagnosis, management, prognosis, and severity of the disease, all health practitioners need to be well acquainted with these Covid-19 skin lesions. Also, in the middle of this worldwide pandemic, early identification of this eruption may help manage this infection's further spread.

From SARS-CoV-2 hematogenous spreading to endothelial dysfunction: clinical-histopathological study of cutaneous signs of COVID-19

BACKGROUND

To date, very few studies on clinical-histopathological correlations of cutaneous disorders associated with COVID-19 have been conducted.

CASE PRESENTATION

The Case 1 was a 90-year-old man, who tested positive for SARS-CoV-2 from a nasopharyngeal swab. Two days later, he was hospitalized and after eleven days transferred to Intensive Care Unit. A chest CT showed bilateral ground-glass opacities. Just that day, an erythematous maculo-papular rash appeared on trunk, shoulders and neck, becoming purpuric after few days. Histological evaluations revealed a chronic superficial dermatitis with purpuric aspects. The superficial and papillary dermis appeared edematous, with a perivascular lympho-granulocytic infiltrate and erythrocytic extravasation. At intraepithelial level, spongiosis and a granulocyte infiltrate were detected. Arterioles, capillaries and post-capillary venules showed endothelial swelling and appeared ectatic. The patient was treated with hydroxychloroquine, azithromycin, lopinavir-ritonavir and tocilizumab. Regrettably, due to severe lung impairment, he died. The Case 2 was a 85-year-old man, admitted to Intensive Care Unit, where he was intubated. He had tested positive for SARS-CoV-2 from a nasopharyngeal swab two days before. A chest RX showed bilateral atypical pneumonia. After seven days, a cutaneous reddening involving trunk, upper limbs, neck and face developed, configuring a sub-erythroderma. Histological evaluations displayed edema in the papillary and superficial reticular dermis, and a perivascular lymphocytic infiltrate in the superficial dermis. The patient was treated with hydroxychloroquine, azithromycin, lopinavir-ritonavir and tocilizumab. Sub-erythroderma as well as respiratory symptoms gradually improved until healing.

CONCLUSIONS

The endothelial swelling detected in the Case 1 could be a morphological expression of SARS-CoV-2-induced endothelial dysfunction. We hypothesize that cutaneous damage could be initiated by endothelial dysfunction, caused by SARS-CoV-2 infection of endothelial cells or induced by immune system activation. The disruption of endothelial integrity could enhance microvascular permeability, extravasation of inflammatory cells and cytokines, with cutaneous injury. The Case 2 developed a sub-erythroderma associated with COVID-19, and a non-specific chronic dermatitis was detected at histological level. We speculate that a purpuric rash could represent the cutaneous sign of a more severe coagulopathy, as highlighted histologically by vascular abnormalities, while a sub-erythroderma could be expression of viral hematogenous spreading, inducing a non-specific chronic dermatitis.

Skin Manifestations in COVID-19 Patients: Are They Indicators for Disease Severity? A Systematic Review

Introduction: Until now, there are several reports on cutaneous manifestations in COVID-19 patients. However, the link between skin manifestations and the severity of the disease remains debatable. We conducted a systematic review to evaluate the temporal relationship between different types of skin lesions and the severity of COVID-19. Methods: A systematic search was conducted for relevant studies published between January and July 2020 using Pubmed/Medline, Embase, and Web of knowledge. The following keywords were used: "SARS-CoV-2" or "COVID-19" or "new coronavirus" or "Wuhan Coronavirus" or "coronavirus disease 2019" and "skin disease" or "skin manifestation" or "cutaneous manifestation." Results: Out of 381 articles, 47 meet the inclusion criteria and a total of 1,847 patients with confirmed COVID-19 were examined. The overall frequency of cutaneous manifestations in COVID-19 patients was 5.95%. The maculopapular rash was the main reported skin involvement (37.3%) commonly occurred in middle-aged females with intermediate severity of the disease. Forty-eight percentage of the patients had a mild, 32% a moderate, and 20% a severe COVID-19 disease. The mild disease was mainly correlated with chilblain-like and urticaria-like lesions and patients with vascular lesions experienced a more severe disease. Seventy-two percentage of patients with chilblain-like lesions improved without any medication. The overall mortality rate was 4.5%. Patients with vascular lesions had the highest mortality rate (18.2%) and patients with urticaria-like lesions had the lowest mortality rate (2.2%). Conclusion: The mere occurrence of skin manifestations in COVID-19 patients is not an indicator for the disease severity, and it highly depends on the type of skin lesions. Chilblain-like and vascular lesions are the ends of a spectrum in which from chilblain-like to vascular lesions, the severity of the disease increases, and the patient's prognosis worsens. Those with vascular lesions should also be considered as high-priority patients for further medical care.

The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature

The diverse clinical manifestations of COVID-19 is emerging as a hallmark of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. While the initial target of SARS-CoV-2 is the respiratory tract, it is becoming increasingly clear that there is a complex interaction between the virus and the immune system ranging from mild to controlling responses to exuberant and dysfunctional multi-tissue directed autoimmune responses. The immune system plays a dual role in COVID-19, being implicated in both the anti-viral response and in the acute progression of the disease, with a dysregulated response represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinflammation. It has been speculated that these immunological changes may induce the loss of tolerance and/or trigger chronic inflammation. In particular, molecular mimicry, bystander activation and epitope spreading are well-established proposed mechanisms to explain this correlation with the likely contribution of HLA alleles. We performed a systematic literature review to evaluate the COVID-19-related autoimmune/rheumatic disorders reported between January and September 2020. In particular, we investigated the cases of incident hematological autoimmune manifestations, connective tissue diseases, antiphospholipid syndrome/antibodies, vasculitis, Kawasaki-like syndromes, acute arthritis, autoimmune-like skin lesions, and neurologic autoimmune conditions such as Guillain-Barré syndrome. We screened 6263 articles and report herein the findings of 382 select reports which allow us to conclude that there are 2 faces of the immune response against SARS-CoV-2, that include a benign virus controlling immune response and a many faceted range of dysregulated multi-tissue and organ directed autoimmune responses that provides a major challenge in the management of this viral disease. The number of cases for each disease varied significantly while there were no reported cases of adult onset Still disease, systemic sclerosis, or inflammatory myositis.

Rare cutaneous manifestation of COVID-19

The COVID-19 pandemic has resulted in an incomparable disease burden worldwide. One of the main contributors stems from the multisystem inflammatory syndrome associated with SARS-CoV-2 infection. The numbers of those affected continue to rise with the increasing number of confirmed COVID-19 cases. However, we are yet to fully comprehend the risk factors, disease progression and prognosis for individuals affected. We describe a case of a previously healthy 17-year-old boy who tested positive for the SARS-CoV-2 virus. He presented with a 5-day history of mild influenza-like symptoms, however, quickly required ventilatory support in the intensive care unit. Two months postdischarge, he developed an isolated petechial rash on his palms and soles. His cutaneous presentation was in association with a mixed sensorimotor peripheral neuropathy, debilitating neuropathic pain and intermittent respiratory distress. We postulate that cutaneous manifestations post-COVID-19 could be indicatory of the newly identified multisystem inflammatory syndrome.

New Onset Granulomatosis with Polyangiitis Associated with COVID-19

The coronavirus disease 2019 (COVID-19) has recently been found to cause cutaneous vasculitis in patients. Granulomatosis with polyangiitis (GPA) is a type of small and medium vessel vasculitis that is often associated with pulmonary issues and has been shown to raise diagnostic complications in COVID-19 infection. In this report, we discuss the first case of new-onset GPA in the setting of active COVID-19 infection. Symptoms often overlap between the two diseases, and while there is no current cure for COVID-19, rapid immunosuppressive initiation can be lifesaving for patients with GPA. Thus, this case is essential in expanding our current knowledge of COVID-19 and its many skin manifestations.

Inflammation and Vascular Injury as the Basis of COVID-19 Skin Changes: Preliminary Analysis of 23 Patients from the Literature

Background

COVID-19 can affect various organ systems including the skin. Cutaneous manifestations of COVID-19 in infected patients are poorly characterized.

Objective

To summarize retrospectively the skin features of COVID-19 infection and to analyze the skin rash incidence rate, clinical onset time, cutaneous manifestations, pathological characteristics and relationship with the novel coronavirus pneumonia severity.

Methods

The literature up to Sep 20, 2020, were searched and analyzed. Information on clinical features including skin manifestations, disease severity, stage and onset day, and cutaneous pathological characteristics was extracted. Data were analyzed using descriptive non-parametric statistics. For categorical data, the number and percentage of patients are presented. A Spearman correlation test was used to analyze the associations between rash type, rash onset and severity of COVID-19. All statistical analysis was performed with IBM SPSS software (version 20) using two-tailed tests. P values <0.05 were considered statistically significant.

Results

Twenty-three cases of COVID-19 patients with cutaneous manifestations from seven reports were collected. Inflammatory dermatosis, skin vasculitis and vascular dermatosis were the main lesion types of COVID-19 patients. Microvascular and endothelial cell injury, perivascular lymphocytic infiltrate, thrombosis, extremely dilated vessels and prominent deposits of C5b-9 were the main dermatologic pathological changes. The onset day analysis showed that out of 19 patients, 63.2% of cutaneous manifestations were within 10 days, 21.1% in 10–20 days and 15.8% were 20 days after the time the patient presented with COVID-19 main symptoms. Spearman rho analysis found no correlation between skin rash type, onset day and COVID-19 severity.

Conclusion

COVID-19 induced skin changes are one of the manifestations of immune responses to the novel coronavirus. Clinical and pathological characteristics were identified as dermal inflammatory reactions and/or skin vascular injury. External or systematic use of anti-inflammatories, protection of blood vessels and circulation-improving medicines should be considered in the skin treatments for novel coronavirus pneumonia patients.

Clinicopathologic correlations of COVID-19-related cutaneous manifestations with special emphasis on histopathologic patterns

Skin is one of target organs affected by the novel coronavirus SARS-CoV-2, and in response to the current COVID-19 pandemic, a fast body of literature has emerged on related cutaneous manifestations. Current perspective is that the skin is not only a bystander of the general cytokines storm with thrombophilic multiorgan injury, but it is directly affected by the epithelial tropism of the virus, as confirmed by the detection of SARS-CoV-2 in endothelial cells and epithelial cells of epidermis and eccrine glands. In contrast with the abundance of epidemiologic and clinical reports, histopathologic characterization of skin manifestations is limited. Without an adequate clinicopathologic correlation, nosology of clinically similar conditions is confusing, and effective association with COVID-19 remains presumptive. Several patients with different types of skin lesions, including the most specific acral chilblains-like lesions, showed negative results at SARS-CoV-2 nasopharyngeal and serologic sampling. The aim of this review is to provide an overview of what has currently been reported worldwide, with a particular emphasis on microscopic patterns of the skin manifestations in patients exposed to or affected by COVID-19. Substantial breakthroughs may occur in the near future from more skin biopsies, improvement of immunohistochemistry studies, RNA detection of SARS-CoV-2 strain by real-time polymerase chain reaction-based assay, and electron microscopic studies.

Clinical manifestation and disease progression in COVID-19 infection

Coronavirus disease 2019 (COVID-19) is mainly an infectious disease of the respiratory system transmitted through air droplets, and pulmonary symptoms constitute main presentations of this disease. However, COVID-19 demonstrates a clinically diverse manifestation ranging from asymptomatic presentation to critically illness with severe pneumonia, acute respiratory distress syndrome, respiratory failure, or multiple organ failure. Accumulating evidences demonstrated that COVID-19 has extrapulmonary involvement, including neurological, smelling sensation, cardiovascular, digestive, hepatobiliary, renal, endocrinologic, dermatologic system, and others. Over a third of COVID-19 patients manifest a wide range of neurological symptoms involving the central/peripheral nervous system. Underlying cardiovascular comorbidities were associated with detrimental outcomes, meanwhile the occurrence of cardiovascular complications correlate to poor survival. Gastrointestinal symptoms frequently occur and have been associated with a longer period of illness. Impaired hepatic functions were associated with the severity of the disease. Higher rate of acute kidney injury was reported in critically ill patients with COVID-19. Endocrinologic presentations of COVID-19 include exacerbating hyperglycemia, euglycemic ketosis, and diabetic ketoacidosis. The most common cutaneous manifestation was acro-cutaneous (pernio or chilblain-like) lesions, and other skin lesions consist of maculopapular rash, vesicular lesions, livedoid/necrotic lesions, exanthematous rashes, and petechiae. This review article summarized the general clinical signs and symptoms, radiologic features, and disease manifestation with progression in patients with COVID-19.

A quantitative exploration of symptoms in COVID-19 patients: an observational cohort study

Background: As the spreading of the COVID-19 around the global, we investigated the characteristics and changes of symptoms in COVID-19 patients. Methods: This was an ambispective observational cohort study, and 133 confirmed COVID-19 patients were included and all symptoms over the course were analyzed qualitatively. The symptoms, their changes over the course in the cohort and in the different clinical types, etc. were illustrated. Differences in different periods and severities were analyzed through Chi square test, association with severity was analyzed through LASSO binomial logistic regression analysis. Inter-correlation and classification of symptoms were completed. Major symptoms were screened and their changes were illustrated. Results: A total of 43 symptoms with frequencies as 6067 in this cohort. Differences of symptoms in different stages and clinical types were significant. Expectoration, shortness of breath, dyspnea, diarrhea, poor appetite were positively but vomiting, waist discomfort, pharyngeal discomfort, acid reflux were negatively correlated with the combined-severe and critical type; dyspnea was correlated with the critical type. The 17 major symptoms were identified. The average daily frequency of symptoms per case was decreased continuously before the transition into the severe type and increased immediately one day before the transition and then decreased. It was decreased continuously before the transition date of the critical type and increased from the transition into the critical type to the next day and decreased thereafter. Dyspnea (P<0.001), shortness of breath (P<0.01) and chest distress (P<0.05) were correlated with death and their corresponding coefficient was 0.393, 0.258, 0.214, respectively. Conclusion: The symptoms of COVID-19 patients mainly related to upper respiratory tract infection, cardiopulmonary function, and digestive system. The mild type and the early stage in other types mainly related to upper respiratory tract infection. The cardiopulmonary function and digestive system associated symptoms were found in all other types and stages. Dyspnea was correlated with critical type, and dyspnea, shortness of breath and chest distress were correlated with death. Respiratory dysfunction (or incompleteness) associated symptoms were the characteristic symptoms. The changes of symptoms did not synchronously with the changes of severity before the transition into the severe or critical type.

Potential interactions of SARS-CoV-2 with human cell receptors in the skin: Understanding the enigma for a lower frequency of skin lesions compared to other tissues

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents a new public health problem, with a total of 10.577.263 documented COVID-19 cases worldwide and 513.441 deaths up to the present date. Few cases of disease-related cutaneous manifestations have been reported in the literature, and such manifestations are scarce. Integumentary manifestations from COVID-19 include exanthemas and papular dermatoses, urticarial eruptions, atopic dermatitis, vesiculobullous lesions and skin signs of hypercoagulable states, such as acral ischaemia, livedo and retiform purpura. Most common extracutaneous manifestations from the disease include headache, cough, anosmia, ageusia, fever, dyspnoea, nausea, diarrhoea and cardiovascular events. The objectives of this review were to discuss the role of human cell receptors described as interaction targets of SARS-CoV-2, as well to understand the current state of knowledge on skin expression of these receptors, in order to substantiate future research. The authors present a thorough literature review on SARS-CoV-2 and its possible interaction with cell receptors and human tissues including the skin. They discuss a molecular hypothesis to explain the lower prevalence of dermatological manifestations from direct SARS-CoV-2 infection. Distinct human cell receptors binding the virus appear to be less expressed in the skin compared to other organs. Additionally, the presence of resolvins and the disintegrin metalloprotease ADAM17 provide a putative protection to the skin, explaining the majority of COVID-19 manifestations to be extracutaneous. This review represents an excellent opportunity for future studies using skin biopsies from COVID-19 patients to investigate molecular expression in the pathophysiology of cutaneous manifestations of the disease.

Cutaneous Manifestations in Confirmed COVID-19 Patients: A Systematic Review

There have been increasing reports of skin manifestations in COVID-19 patients. We conducted a systematic review and included manuscripts describing patients with positive RT-PCR coronavirus testing from nasopharyngeal swabs who also developed cutaneous manifestations. A total of 655 patients were selected, with different types of skin rashes: Erythematous maculopapular (n = 250), vascular (n = 146), vesicular (n = 99), urticarial (n = 98), erythema multiforme/generalized pustular figurate erythema/Stevens-Johnson syndrome (n = 22), ocular/periocular (n = 14), polymorphic pattern (n = 9), generalized pruritus (n = 8), Kawasaki disease (n = 5), atypical erythema nodosum (n = 3), and atypical Sweet syndrome (n = 1). Chilblain-like lesions were more frequent in the younger population and were linked to a milder disease course, while fixed livedo racemosa and retiform purpura appeared in older patients and seemed to predict a more severe prognosis. For vesicular rashes, PCR determined the presence of herpesviruses in the vesicle fluid, which raised the possibility of herpesvirus co-infections. The erythema-multiforme-like pattern, generalized pustular figurate erythema and Stevens-Johnson syndrome were most frequently linked to hydroxychloroquine intake. A positive PCR determination of SARS-COV-2 from conjunctival swabs suggest that eye discharge can also be contagious. These cutaneous manifestations may aid in identifying otherwise asymptomatic COVID-19 carriers in some cases or predict a more severe evolution in others.

Dermatologic manifestations of COVID-19: a comprehensive systematic review

Recent reports have suggested that there may be dermatologic manifestations of COVID-19. We searched 12 databases for peer-reviewed or pre-print published studies until July 15, 2020, for this PRISMA-compliant review (CRD42020182050). We used the Oxford Center for Evidence-Based Medicine Levels of Evidence to facilitate data synthesis. From 86 retrieved studies, we collated data on 2,560 patients with dermatologic manifestations of COVID-19. The most common findings were chilblains/pernio-like lesion (51.5%), erythematous maculopapular rashes (13.3%), and viral exanthem (7.7%). Average pediatric age was 12.9 years (SD 3.6) and adult was 34.2 years (SD 21.8). Average latency from time of upper respiratory illness symptoms to cutaneous findings was 1.5 days (SD 2.9) in children and 7.9 days (SD 10.7) in adults, ranging from -3 to 38 days. Roughly one-tenth in both populations were otherwise asymptomatic or presented with only skin findings for the entirety of the disease course; 13.3% (pediatrics) and 5.3% (adults) presented with skin issues first. Dermatologic findings may play an important role in identifying cases early and serve as an important proxy to manage spread. Further prospective data collection with international prospective registries is needed.

COVID-19 and cutaneous manifestations: a systematic review

The cutaneous manifestations of COVID-19 patients have been increasingly reported, but not summarized, and the potential mechanisms remain to be investigated. Herein, we performed a comprehensive review of literatures (from inception to 30 May 2020) using PubMed, CNKI, medRxiv and bioRxiv with the terms "((novel coronavirus) OR (2019 novel coronavirus) OR (2019-nCoV) OR (Coronavirus disease 2019) OR (COVID-19) OR (SARS-CoV-2)) AND ((Dermatology) OR (skin) OR (rash) OR (cutaneous))" and "((ACE2) OR (Angiotensin-converting enzyme)) AND ((skin) OR (epidermis) OR (dermis))." Totally, 44 articles met the inclusion criteria. A total of 507 patients with cutaneous manifestations were summarized, and 96.25% patients were from Europe. The average age of the patients was 49.03 (range: 5-91) with a female ratio of 60.44%. The skin lesions were polymorphic, and erythema, chilblain-like and urticarial lesions were most common, occurring on an average of 9.92 days (range: 1-30) after the onset of systemic symptoms. The receptor of SARS-CoV-2, ACE2, was found to be expressed on skin, mainly on keratinocytes. Our review systematically presented the clinical characteristics of 507 patients and showed that skin might be the potential target of the infection according to ACE2 expression. More work should be done to better understand the underlying pathogenesis.

Maculopapular eruptions associated to COVID-19: A subanalysis of the COVID-Piel study

A previous study has defined the maculopapular subtype of manifestations of COVID-19. The objective of our study was to describe and classify maculopapular eruptions associated with COVI-19. We carried out a subanalysis of the maculopapular cases found in the previous cross-sectional study. Using a consensus, we defined seven clinical patterns. We described patient demographics, the therapy received by the patient and the characteristics of each pattern. Consensus lead to the description of seven major maculopapular patterns: morbilliform (45.5%), other maculopapular (20.0%), purpuric (14.2%), erythema multiforme-like (9.7%), pytiriasis rosea-like (5.7%), erythema elevatum diutinum-like (2.3%), and perifollicular (2.3%). In most cases, maculopapular eruptions were coincident (61.9%) or subsequent (34.1%) to the onset of other COVID-19 manifestations. The most frequent were cough (76%), dyspnea (72%), fever (88%), and astenia (62%). Hospital admission due to pneumonia was frequent (61%). Drug intake was frequent (78%). Laboratory alterations associated with maculo-papular eruptions were high C-reactive protein, high D-Dimer, lymphopenia, high ferritin, high LDH, and high IL-6. The main limitation of our study was the impossibility to define the cause-effect relationship of each pattern. In conclusion, we provide a description of the cutaneous maculopapular manifestations associated with COVID-19. The cutaneous manifestations of COVID-19 are wide-ranging and can mimic other dermatoses.

Patients with specific skin disorders who are affected by COVID-19: What do experiences say about management strategies? A systematic review

In patients with specific dermatologic disorders who are affected by new corona virus, we know little about disease course (underlying disease and new onset infection), and the most proper management strategies include both issues that are what this systematic review targets. Databases of PubMed, Scopus, Google Scholar, Medscape, and Centre of Evidence-Based Dermatology, coronavirus dermatology resource of Nottingham University searched completely up to May 15, 2020, and initial 237 articles were selected to further review and finally 9 articles (including 12 patients) entered to this study. From 12 patients with chronic underlying dermatologic disease treated with systemic therapies, only 1 patient required Intensive Care Unit admission, the others have been treated for mild-moderate symptoms with conventional therapies. The biologic or immunosuppressive/immunomodulator agents have been ceased during the course of disease. The course of coronovirus diseases 2019 (COVID-19) and its management was as similar as normal populations. Their underlying dermatologic disease were exacerbating from mild to moderate. Their treatment has been continued as before, after the symptoms improved. Exacerbation of patients underlying dermatologic disease was mild to moderate. Discontinuing the treatment in the acute period of COVID and the restart after recovery may prevent severe recurrence and disturbing cytokine storms in these patients.

Cutaneous, skin histopathological manifestations and relationship to COVID-19 infection patients

COVID-19 diseases have been a nationwide pandemic condition. However, cutaneous, skin histopathological manifestations of COVID-19 infection are not well described. Our study aims are to present heterogeneous cutaneous, histopathological manifestations in COVID-19 patients, to investigate the possible relationship between cutaneous manifestations and histopathological features in COVID-19 infection. We performed a systemic review in PubMed database and Chinese medical journal search engines which were wangfang.data (http://www.wanfangdata.com.cn/), Science China (http://www.cnki.net/) until June 17th, 2020. Search terms "COVID-19," "SARS-Coronavirus-2" and "Coronavirus" were used in combination with "cutaneous," "rash," "skin," "dermatology." Seventy-five papers were included with confirmed COVID-19 infection. The most frequent cutaneous manifestation of COVID-19 present was erythema, nearly 38.4%. Trunk was the most affected location, presenting in 51.4% patients. Rash occurred before onset of other symptoms was in 5.3% patients. Seventy-seven patients were received treatments. Rash was dismissed in 49% patients, improved in 21.2% patients ranged from 0 to 17 days. The histopathological examination present in 39 patients. Skin is one of target organs affected by COVID-19 infection. Cutaneous manifestations should be paid more attention. It can help doctors diagnose COVID-19 infection in prodromal stage, understand progression, and determine prognosis of COVID-19 infection.

COVID-19 and Skin Manifestations: An Overview of Case Reports/Case Series and Meta-Analysis of Prevalence Studies

Background and Aim: Since the onset of the 2019-nCoV disease (COVID-19), many skin manifestations have been reported in COVID-19 patients. This study aims to provide a systematic review and meta-analysis of various skin manifestations among patients with COVID-19 through case reports/case series and prevalence studies. Methods: A systematic literature search strategy was conducted by reviewing original research articles published in Medline, Web of Science, and Embase databases in 2020. Statistical analysis was performed using STATA software, version 14.0 (Stata Corporation, College Station, Texas, USA) to report the global prevalence of skin manifestations among patients with COVID-19. Results: Forty-three studies (35 articles were case reports/case series, and 8 articles were prevalence studies) were included in our study. A meta-analysis of prevalence studies showed that skin manifestations among patients with COVID-19 were reported in four countries (China, Thailand, France, and Italy), with an overall prevalence of 1.0% [(95% CI) 0.1-1.9] among 2,621 patients. Evaluation of the results of the case reports/case series revealed that, out of 54 patients with COVID-19, 48 patients (88.8%) showed skin manifestations. Erythematous rash (59.1%) and urticaria (14.8%) were the most common skin manifestation reported in studied patients. Conclusion: Infection with 2019-nCoV may lead to skin manifestations with various clinical symptoms. These clinical features combined with clinical symptoms of COVID-19 may aid in the timely diagnosis of patients with COVID-19.

Delayed Presentation of Acute Generalized Exanthematous Pustulosis Following Treatment with Cefepime in a Patient with COVID-19 without the Use of Hydroxychloroquine

Patient: Male, 78-year-old

Final Diagnosis: Acute generalized exanthematous pustulosis (AGEP)

Symptoms: Rash

Medication:—

Clinical Procedure: —

Specialty: Allergology • Infectious Diseases

Difficulties in differential diagnosis of cutaneous manifestations in patients with coronavirus infection

Patients with severe SARS-CoV-2 infection (COVID-19) and multiple comorbidities should be monitored for possible adverse reactions to prescribed drugs, including drug eruptions (DE) at any stage of treatment. Below, we describe a clinical case of a 92-year-old female patient with severe PCR-confirmed COVID-19. The patient was treated with amoxicillin/clavulanic acid, moxifloxacin, acetylcysteine, and sodium enoxaparin. On day 9 into treatment, the patient developed moderately itching macular rashes showing a tendency to coalesce, but overall showed no signs of deterioration. On day 15, the rashes regressed, following a short course of dexamethasone and chloropyramine. This kind of skin reaction might have been provoked by β-lactams and fluoroquinolones included in the treatment regimen, a secondary bacterial infection, compromised immunity due to advanced age, and high viral load associated with dermatological symptoms. Delayed onset of skin symptoms might be regarded as a marker of COVID-19 severity.

Skin Manifestations in COVID-19: Prevalence and Relationship with Disease Severity

BACKGROUND

Data on the clinical patterns and histopathology of SARS-CoV-2 related skin lesions, as well as on their relationship with the severity of COVID-19 are limited.

METHODS AND MATERIALS

Retrospective analysis of a prospectively collected cohort of patients with SARS-CoV-2 infection in a teaching hospital in Barcelona, Spain, from 1 April to 1 May 2020. Clinical, microbiological and therapeutic characteristics, clinicopathological patterns of skin lesions, and direct immunofluorescence and immunohistochemical findings in skin biopsies were analyzed.

RESULTS

Fifty-eight out of the 2761 patients (2.1%) either consulting to the emergency room or admitted to the hospital for COVID-19 suspicion during the study period presented COVID-19 related skin lesions. Cutaneous lesions could be categorized into six patterns represented by the acronym "GROUCH": Generalized maculo-papular (20.7%), Grover's disease and other papulo-vesicular eruptions (13.8%), livedo Reticularis (6.9%), Other eruptions (22.4%), Urticarial (6.9%), and CHilblain-like (29.3%). Skin biopsies were performed in 72.4%, including direct immunofluorescence in 71.4% and immunohistochemistry in 28.6%. Patients with chilblain-like lesions exhibited a characteristic histology and were significantly younger and presented lower rates of systemic symptoms, radiological lung infiltrates and analytical abnormalities, and hospital and ICU admission compared to the rest of patients.

CONCLUSION

Cutaneous lesions in patients with COVID-19 appear to be relatively rare and varied. Patients with chilblain-like lesions have a characteristic clinicopathological pattern and a less severe presentation of COVID-19.

The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries

BACKGROUND

Coronavirus disease 2019 (COVID-19) has associated cutaneous manifestations.

OBJECTIVE

To characterize the diversity of cutaneous manifestations of COVID-19 and facilitate understanding of the underlying pathophysiology.

METHODS

Case series from an international registry from the American Academy of Dermatology and International League of Dermatological Societies.

RESULTS

The registry collected 716 cases of new-onset dermatologic symptoms in patients with confirmed/suspected COVID-19. Of the 171 patients in the registry with laboratory-confirmed COVID-19, the most common morphologies were morbilliform (22%), pernio-like (18%), urticarial (16%), macular erythema (13%), vesicular (11%), papulosquamous (9.9%), and retiform purpura (6.4%). Pernio-like lesions were common in patients with mild disease, whereas retiform purpura presented exclusively in ill, hospitalized patients.

LIMITATIONS

We cannot estimate incidence or prevalence. Confirmation bias is possible.

CONCLUSIONS

This study highlights the array of cutaneous manifestations associated with COVID-19. Many morphologies were nonspecific, whereas others may provide insight into potential immune or inflammatory pathways in COVID-19 pathophysiology.

From quarantine room: Physician perspective

This write-up is a brief reflection of a rural doctor couple, Dr. Himmatrao Saluba Bawaskar (HSB) and Dr. Pramodini Himmatrao Bawaskar (PHB), working in the remote area of Maharashtra state of India during COVID-19 pandemic. During the pandemic, rural doctors are routinely exposed to symptomatic COVID-positive cases in the outpatient as well as indoor setting. The authors, both husband and wife, were in compulsory quarantine for twice at home and experienced social stigmas attached to a positive case. Here is a report the details of COVID-19 pattern and its management learned from the published scientific papers on COVID-19, and severe acute respiratory syndrome due to SARS-CoV-2 from December 2019 and their own experience in rural setting and the current literature shared in the form of personal narration. Apart from the personal experience of patients experience regarding quarantine period, COVID-19 is discussed in detail for the benefit of rural practitioners.