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

Diagnosis and management of COVID toes in outpatients: a case report

BACKGROUND

Since the beginning of the coronavirus disease 2019 pandemic, the most common skin lesions observed due to infection with the severe acute respiratory syndrome coronavirus 2 are pseudochilblains (or coronavirus disease toes). However, this pathology remains infrequent and difficult to diagnose, as no specific test exists.

CASE PRESENTATION

Two Caucasian women, 30 and 22 years old, presented to our General Medicine Unit with perniosis lesions on the feet during the first two waves of the coronavirus disease 2019 pandemic. They did not have respiratory or general symptoms of severe acute respiratory syndrome coronavirus 2 infection, the reverse transcription polymerase chain reaction on nasopharyngeal swabs was negative, and the serology was positive only in the first case. The clinical presentation differed for the two cases, as the second patient suffered from swelling and burning after cold application. The diagnosis was based on clinical presentation, temporality, exclusion of other differential diagnoses, and blood test results (positive serology in the first case and high level of CXCL13 and VEGF in the second), supported by current literature. Lesions resolved spontaneously in the first patient. The second case was hospitalized for pain management and received corticosteroid therapy with resolution of the symptoms.

CONCLUSION

These two cases with different clinical presentations illustrate the diagnostic approach to coronavirus disease 2019, a challenging disease with diverse manifestations, including, in some cases, coronavirus disease toes. We present a literature review that illustrates the progression of scientific research. Skin lesions associated with coronavirus disease 2019 infection could be the expression of an important interferon type 1 response and should be considered in the differential diagnosis in a primary care setting.

COVID-19: THE NEED FOR INCREASED RECOGNITION OF CUTANEOUS MANIFESTATIONS - LETTER TO THE EDITOR

t has been over three years since the first case of covid-19 was discovered in Wuhan, China. Since then, there have been a lot of discussions around symptoms and sequelae of covid-19 such as respiratory, cardiac, and neurology problems. However, not a lot of attention has been drawn to skin manifestations of this disease despite the fact that the prevalence of covid-19 associated skin lesions could be as high as 20% in some countries (Tan et al., 2021)

Defining the short-term and long-term skin manifestations of COVID-19: insights after more than three years of the pandemic

AIM

This review aimed to assess the impact of coronavirus disease 2019 (COVID-19) on skin health to establish a classification of the skin lesions that occur most frequently during the disease and whether a particular category of skin damage is more likely to occur both in the short term and in the long term.

METHODS

We conducted a literature search of the PubMed database. Ultimately, 109 articles were included in this review. The exact phrases∕syntax and connectors used for the database search∕query were as follows: "Coronavirus and skin", "COVID-19 and skin", "SARS-CoV-2 and skin", "Coronavirus cutaneous manifestations", "COVID-19 cutaneous manifestations", "SARS-CoV-2 cutaneous manifestations", "Coronavirus dermatology", "SARS-CoV-2 and dermatology", "COVID-19 and dermatology", "COVID-19 and skin eruption", "Coronavirus and skin rash", "COVID-19 and hair", "Coronavirus and hair", "Coronavirus and nails", "SARS-CoV-2 and hair", and "SARS-CoV-2 and nails". Only articles with abstracts referring strictly to cutaneous manifestations of COVID-19 were chosen. Articles without abstracts were not considered.

RESULTS

We established six of the most frequently reported clinical patterns associated with COVID-19 and their probability of occurring during COVID-19 disease evolution based on the current literature reports. We did not identify the particular types of skin lesions that are most prone to long-term persistence; most such cases are rare, and no conclusion can be drawn based on them.

CONCLUSIONS

Apart from classified COVID-19-related skin disorders, this pandemic has been a challenge for dermatologists and a wide range of cutaneous side effects related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) treatments have been reported. We are aware of other polymorphic clinical presentations, with novel data being reported periodically, but the pathophysiological mechanisms and evolution are largely unknown.

Increased Frequency of Hand Hygiene and Other Infection Prevention Practices Correlates with Reduced Surgical Wound Infection Rates in Spinal Surgery during the COVID-19 Pandemic

BACKGROUND

Due to the COVID-19 pandemic outbreak, many changes were done in the hospital practice, and new guidelines were issued in order to contain the infection spread. One of the most common measures is represented by a correct and frequent hand washing. Recently, an association between increased adherence to hand hygiene (HH) protocols and reduction in hospital infections was documented however no studies about the surgical wound infection rate were reported in the Literature.

METHODS

The present study represents a multicentric retrospective epidemiological study. The HH compliance rate was recorded through direct observations by trained nurses, 24 h a day. The primary outcome was HH compliance rate. The association of HH with spinal surgical wound infections was the secondary outcome.

RESULTS

We reported a compliance to HH practices during the pandemic period of 85.2% compared with 57% observed during 2019. Our analysis showed an overall surgical wound infection reduction of 66.6% during the hospital stay in the pandemic period.

CONCLUSION

Hand hygiene has always been considered one of the most effective, reproducible and low-cost weapons to deal with hospital infections. The good health habits acquired during the COVID-19 pandemic should be maintained even after the virus is eradicated.

Cutaneous Eruptions in the Course of COVID-19 Among Geriatric Patients in a Nursing Home in Poland

Purpose

The aim of this study was to assess the incidence and characteristics of COVID-19 cutaneous manifestations among geriatric patients infected with the SARS-CoV-2 virus.

Patients and Methods

Sixty-four nursing home residents in Dobre Miasto, Poland (mean age: 79 years) infected with SARS-CoV-2 were monitored for skin lesions during the epidemic outbreak in 2020. Only five of them presented COVID-19 dermatological manifestation: vesicular (4 cases) and erythematous (1 case) skin lesions, which appeared after the remaining symptoms of the disease had resolved.

Results

The average time between COVID-19 onset and cutaneous manifestation was 22 days. Skin lesions persisted in five cases 112, 17, 21,19 and 27 days, respectively, and were often accompanied by pruritus and neuropathic pain.

Conclusion

Skin manifestations of SARS-CoV-2 infection might be misdiagnosed or overlooked, particularly among elderly patients with chronic diseases. The recognition of skin lesions due to COVID-19 might improve patients' quality of life by reducing the intensity of symptoms such as pruritus or neuropathic pain.

The Impact of COVID-19 Pandemic on Dermatological Conditions: A Novel, Comprehensive Review

Background: The earliest cases of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in December 2019. Since the declaration as a pandemic on 11 March 2020, further dermatological conditions continue to be documented. We herein present a novel literature review of dermatological manifestations associated with the Coronavirus Disease 2019 (COVID-19) pandemic. To date, this literature review is the first broad-spectrum examination that analyzes a range of dermatological manifestations related to the COVID-19 pandemic: infection, vaccinations, personal protective equipment (PPE), and psychosocial factors. Methods: A detailed literature search was conducted using key terms for cutaneous manifestations associated with the scope of this review. The search retrieved 2199 articles. Results: The COVID-19 pandemic has triggered a significant range of dermatologic sequela. Etiologies of lesions continue to be investigated. Proposed mechanisms include inflammatory response to spike protein, vitamin D deficiency, ACE2 receptor activation, androgen levels, and increased psychological stress. One prominent mechanism describes viral spike protein invasion into the dermis by binding to the angiotensin-converting enzyme 2 (ACE-2) receptors in keratinocytes, with a secondary immunological response. Conclusions: Dermatologists play an integral role in the proper diagnosis and treatment of COVID-related lesions. Early treatment regimens and timely prophylaxis have been shown to safely reduce infection-related dermatological sequelae. Additional investigations and data collection can reduce disease burden and improve overall prognosis.

Is it time to resume elective knee arthroplasty surgery? A multidisciplinary experience in a Sardinian center during the SARS-CoV-2 pandemic

Background

Starting in January 2020, the SARS-CoV-2 pandemic caused changes in the nation's health systems. The hospital's reorganization led to a near-total stop of non-urgent, elective surgeries across all specialties, including hip and knee arthroplasty. However, in May 2020, a gradual elective surgery restarting was possible. Considering the risk of COVID-19 infections, the European Knee Associates suggest the need to implement specific protocols for a safe return to orthopaedic elective surgery.

Methods

A retrospective analysis regarding all patients who underwent primary knee arthroplasty (TKA) between March 1st and October 1st, 2020 using an institutional database was performed. The study time was divided into 2 periods: Pandemic (from March 2020 to May 2020), Post Pandemic (from June 2020 to October 2020). A specific protocol was designed to safeguard the health of patients and healthcare workers during the SARS-CoV-2 pandemic.

Results

A total of 147 patients underwent total knee replacement surgery in the analyzed period. The mean surgical time was 77.6 (+/-18.9). The intraoperative mean blood loss was 54 (+/-28) ml. The mean hospital stay was 3-4 days. Among the treated patients no case of COVID-19 infection was observed.

Conclusion

The use of our protocol, developed ad hoc for the management of elective orthopedic patients, allowed the restart of elective orthopedic surgery in a safe and reproducible way with an average increase of 374% on surgical activity between the pandemic and post-pandemic periods without record cases of contagion among the treated patients.

Herpes Zoster in the era of COVID 19: A prospective observational study to probe the association of herpes zoster with COVID 19 infection and vaccination

BACKGROUND

Herpes zoster (HZ) is caused by reactivation of the latent varicella zoster virus (VZV) following decline in cell-mediated immunity. All over the world, in the past couple of years, the Corona Virus 2019 (COVID-19) has emerged as a viral cause of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection. Based on the current limited evidence, co-infection of COVID-19 with varicella zoster virus or reactivation of VZV after COVID-19 vaccination has been sporadically reported.

METHODS

All patients diagnosed with HZ, in Farwaniya Hospital in Kuwait, from March 2020 to July, 2021, having either (A) a positive COVID-19 Polymerase Chain Reaction (PCR) test or (B) been vaccinated against SARS-CoV-2 were enrolled in the study. All patients' demographic information, medical history, laboratory findings, and vaccination status was documented. All statistical analyses were performed using SPSS Statistics version 21.0 software.

RESULTS

Twelve cases infected with COVID-19 with a positive PCR (group 1) and five cases vaccinated against SARS-CoV-2 (group 2) were documented. Out of the twelve COVID-19 infected patients (group 1), only two patients (16.67%) required hospitalization, while the remaining ten patients had mild/moderate lymphopenia. Furthermore, among the twelve positive COVID-19 cases, four patients with HZ were diagnosed within the first week of COVID-19, while the remaining eight cases were diagnosed within eight weeks of COVID-19. Thoracic segments were affected in five cases (41.67%), cervical in one case (8.33%), cranial in two cases (16.67), lumbar in three cases (25.00%) and sacral in one case (8.33%). In group 2, three patients presented with HZ within four weeks of having received the first dose of the vaccine and two patients after the second dose. Blood investigations for all five vaccinated patients did not show any abnormalities. Cervical segments were affected in two patients (40%), and cranial, thoracic and lumbar segment in the remaining patients respectively (20%).

CONCLUSIONS

Experts must be aware of the probable increased risk of HZ during the Covid 19 pandemic. We propose appropriate curative and preventive measures against herpes zoster infection, including a systematic follow-up of these patients to ensure that they stick to extreme safety measures till the diagnosis of COVID-19 is omitted This article is protected by copyright. All rights reserved.

One Year of COVID-19: Lessons Learned in a Hand Trauma Center

2020 will be remembered worldwide as the year of COVID-19 outbreak. The onset of this pandemic abruptly changed everybody’s life and, in a particular manner, doctors’ lives. Our hand surgery department became rapidly one of the first COVID-19-specialized wards in Italy, impacting considerably the authors’ routines and activities. In this paper, the authors focus on how the demographics of patients with hand trauma changed and how they had to modify their activity. The authors retrospectively took into consideration all patients reaching their emergency department (ED) with hand trauma between 9 March 2020 (the day of the beginning of the first lockdown in Italy) and 8 March 2021 and compared them to those who reached the ED in the three previous years. Authors have analyzed the number of patients, their gender and age, the severity of their trauma, where the trauma occurred, the type of lesion, the percentage of patients who underwent surgery, and the percentage of patients who had an emergency admission. In the last year, the number of patients reaching the ED for a hand trauma has been reduced by two thirds (975 patients during the past year), the mean age of those patients has slightly increased, the severity of cases has increased, places of trauma and type of lesions have changed, and, lastly, the percentage of patients needing surgery who were admitted immediately has increased. This paper shows how the type of patients reaching the ED changed and discusses how surgeons evolved and modified their habits in treating those patients during the first lockdown and the year that followed.

Toxic Epidermal Necrolysis associated with COVID-19 infection: A case report

Toxic Epidermal Necrolysis/Steven-Johnson Syndrome (TEN/SJS) is one of the most serious dermatological adverse reactions triggered mainly by drugs and less likely by infections. COVID-19 disease is caused by Sever Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) with a wide range of clinical manifestations. Skin involvement is common in COVID-19 patients including urticaria, purpura, and vasculitis. There were reported cases of TEN/SJS in adults with COVID-19 infections and only two reported cases in pediatric patients. The causality relationship between COVID-19 infection and TEN/SJS was not established in most cases due to history of drug usage that could be the trigger. In this study, we are reporting a case of previously healthy child apart from COVID-19 infection who was admitted to the intensive care unit with TEN involving more than 30% of body surface area confirmed by skin biopsy. The child was treated with intravenous immunoglobulins, steroids, and cyclosporin with a very good outcome.

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.

Paucity of cutaneous manifestations of COVID-19 among inpatients in a referral hospital in India

Background

Varied cutaneous manifestations of COVID-19 have been described, but most studies are based on photographic or application-based observations, without a direct observed-based evaluation by dermatologists.

Objective

To study the types of cutaneous manifestations of COVID-19 among confirmed inpatients admitted to COVID-19 wards and intensive care units (ICUs).

Methods

This cross-sectional analysis was conducted at a referral hospital in Delhi, India. Four hundred forty consecutive reverse transcription-polymerase chain reaction (RT-PCR)–confirmed cases diagnosed with moderate or severe COVID-19 and admitted to COVID-19 wards or ICUs, respectively, were included. A cutaneous finding was considered to be associated with COVID-19 if it had been described earlier as a consequence of COVID-19 and was observed at the time of or within the first 48 hours of admission (after excluding drugs and comorbidities as causes).

Results

Two hundred seventy patients with moderate COVID-19 were admitted to COVID-19 wards, whereas 170 with severe disease were admitted to ICUs. Only 7 of the 270 ward patients (2.59%) and 3 of the 170 ICU patients (1.76%) had cutaneous findings associated with COVID-19.

Conclusion

Cutaneous findings attributable to COVID-19 are infrequent, and we believe that these might have been overestimated or overemphasized in earlier studies. Although coagulopathic findings may be associated with severe COVID-19, causation cannot be established in this cross-sectional study.

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.

Identification, Mechanism, and Treatment of Skin Lesions in COVID-19: A Review

Coronavirus disease 2019 (COVID-19) is a multisystem disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), that primarily causes respiratory symptoms. However, an increasing number of cutaneous manifestations associated with this disease have been reported. The aim of this study is to analyze the scientific literature on cutaneous manifestations associated with SARS-CoV-2 by means of a narrative literature review until June 2021. The search was conducted in the following electronic databases: Medline (PubMed), SciELO, and Cochrane Library Plus. The most common cutaneous manifestations in patients with COVID-19 are vesicular eruptions, petechial/purpuric rashes, acral lesions, liveoid lesions, urticarial rash, and maculopapular-erythematous rash. These manifestations may be the first presenting symptoms of SARS-CoV-2 infection, as is the case with acral lesions, vesicular eruptions, and urticaria. In relation to severity, the presence of liveoid lesions may be associated with a more severe course of the disease. Treatment used for dermatological lesions includes therapy with anticoagulants, corticosteroids, and antihistamines. Knowledge of the dermatologic manifestations associated with SARS-CoV-2 contributes to the diagnosis of COVID-19 in patients with skin lesions associated with respiratory symptoms or in asymptomatic patients. In addition, understanding the dermatologic lesions associated with COVID-19 could be useful to establish a personalized care plan.

[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.

COVID-19 and the clinical course of rheumatic manifestations

The manifestations of COVID-19 have been evolving over time. Various post-COVID-19 syndromes are being recognised. Various viruses have been implicated in the pathogenesis of autoimmune diseases, and we expect a similar outcome with the severe acute respiratory syndrome-associated coronavirus-2 (SARS-CoV-2). The SARS-CoV-2 virus penetrates various tissues and organs and has a predisposition to lead to endotheliitis that may cause vascular manifestations including thrombosis. SARS-CoV-2 has been shown to activate Toll-like receptors and the complement system. It perpetuates NETosis and leads to autoantibody formation. These predispose to systemic autoimmunity. Both reactive arthritis and connective tissue disorders such as lupus and inflammatory myositis have been reported after COVID-19. Other reported autoimmune disorders include haemolytic anaemia, immune thrombocytopenia, cutaneous vasculitis, and Guillain Barré-like acute demyelinating disorders. The multi-system inflammatory syndrome in children and its adult counterpart are another post-COVID-19 entity that presents as an admixture of Kawasaki disease and staphylococcal toxic shock syndrome. Patients with preexisting rheumatic diseases may flare during the SARS-CoV-2 infection. They may develop novel autoimmune features also. The immune-suppressants used during the acute COVID-19 illness may confound the outcomes whereas comorbidities present in patients with rheumatic diseases may mask them. There is an urgent need to follow-up patients recovering from COVID and monitor autoantibody production in the context of rheumatic manifestations. Key Points • COVID-19 is associated with both innate and acquired immune reactions and production of various autoantibodies. • Various immune-mediated manifestations such as arthritis, myositis, haemolytic anaemia, thrombocytopenia, and acute demyelination may develop after COVID-19. • Longitudinal cohort data are warranted to describe, predict, and test prevent various rheumatic manifestations in post-COVID-19 subjects.

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.