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First observations: Skin manifestations of COVID-19 infection

In this COVID-perspective 3 specialists in dermato-venereology reviews on some of the limited available literature about skin manifestations in COVID-19.

Virus induced in the initial phase and late manifestations

A group of dermatologists from Lecco in Italy collected data from 88 patients with COVID-19. Eighteen patients (20.4%) developed cutaneous manifestations. Eight patients developed cutaneous involvement at the onset, 10 patients only after hospitalization. The cutaneous manifestations seen were erythematous rash (14 patients), widespread urticaria (3 patients), and chickenpox like vesicles (1 patient). The skin on the trunk was the main involved region. Itching was insignificant or absent and usually lesions healed in a few days. Apparently, there was no correlation between skin symptoms and disease severity. It was concluded that skin manifestations related to COVID-19 infection are comparable to those occurring during common viral infections.1 Similar findings in the initial phase are seen in Chinese case reports.2-5

A case report from Thailand presented a patient with a skin rash with petechiae. Because dengue is very common in Thailand and the patient also had low platelet count, a clinical diagnosis of dengue was made by the first physician in-charge. In this case, the patient further presented respiratory problems and was referred to the tertiary medical center. Other common virus infections that might cause fever, rash and respiratory problems were ruled out by laboratory investigation and the final diagnosis of COVID-19 infection was confirmed by RT-PCR.6 According to the study, it is a possible to misdiagnose a patient with an initiated skin rash with other common diseases – thereby possible overseeing COVID-19. Additionally, some of these COVID-19 patients were afebrile initially. More case reports from China present COVID-19 patients with urticaria as a clinical cutaneous manifestation.7

Another study from Wuhan registered the clinical characteristics of 140 community-infected patients with COVID-19. It was found that the median age of all patients were 57 years old with almost 1:1 male/female ratio. Fever (91.7 %), cough (75.0%) and fatigue (75%), were the most common symptoms in COVID-19 patients. More than 1/3 of the patients had chest tightness or dyspnoea and gastrointestinal symptoms (nausea, diarrhoea, and anorexia). CT scans or X-ray showed bilateral ground-glass and patchy opacity in 89.6% of the patients. No asthmatic patients were identified in this report, and only a few patients had self-reported drug hypersensitivity and urticaria. Other allergies such as allergic rhinitis, atopic dermatitis, and food allergy were not reported.8

Complications in the skin, non-specific, not directly virus induced

A retrospective study found 7 critical COVID-19 patients with acro-ischaemia in a single center in Wuhan. All patients had acro-ischaemia presentations including finger/toe cyanosis, skin bullae and dry gangrene. D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients. Prothrombin time (PT) were prolonged in 4 patients. D-dimer and FDP levels increased progressively when COVID-19 exacerbated, and 4 patients were diagnosed with definite disseminated intravascular coagulation (DIC). Six patients received low molecular weight heparin (LMWH) treatment, after which their D-dimer and FDP decreased, but there was no significant improvement in clinical symptoms. Five patients died finally and the median time from acro-ischaemia to death was 12 days. It was concluded that hypercoagulation status in critical COVID-19 patients should be monitored closely, and that anticoagulation therapy should be considered in selected patients.9


Data from studies concerning cutaneous manifestations in patients with COVID-19 varies a lot. Nevertheless, dermatologists should recognize the possibility that COVID-19 patients might present with only a skin rash initially and should think of the possibility of the patient having COVID-19 in order to prevent further transmission. Dermatologists have to be aware of complications seen in the skin can be an early sign of a progression to very severe COVID-19.


  1. Recalcati SJ. Skin manifestations of coronavirus cutaneous manifestations in COVID-19: a first perspective. Letter to Editor. Eur Acad Dermatol Venereol 2020 Mar 26. doi: 10.1111/jdv.16387.
  2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507–513.
  3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497–506.
  4. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323: 1061–1069. 5.
  5. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020 Feb 28. doi 10.1056/ NEJMoa2002032. Epub ahead of print.
  6. Joob, B, Wiwanitkit, V. COVID-19 can present with a rash and be mistaken for Dengue. J Am Acad Dermatol 2020, Mar 22, doi: j.jaad.2020.03.036.
  7. Shubiao L, Linsong L, Zhiqiao Z, Xiao L, Jiang Z, Chen J, et al. Alert for non-respiratory symptoms of Coronavirus Disease 2019 (COVID-19) patients in epidemic period: A case report of familial cluster with three asymptomatic COVID-19 patients. J Med Virol 2020, March 19. doi: 10.1002/jmv.25776. [Epub ahead of print]
  8. Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy EAACI March 2020, doi: 10.1111/all.14238.
  9. Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-19 pneumonia and acro-ischemia. Zhonghua Xue Ye Xue ZA Zhi 2020 Mar 28;41(0).

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