Cutaneous Manifestations of COVID-19: Characteristics, Pathogenesis, and the Role of Dermatology in the Pandemic
Cutaneous manifestations of COVID-19—SARS-CoV-2—are common and varied. Morbilliform, vesicular, and urticarial eruptions may be nonspecific initial features of the disease. Chilblainlike lesions on the fingers or toes typically occur as part of a resolution phase, signifying a milder course, whereas livedoid lesions and retiform purpura are associated with coaguloapthy and more severe disease. Additionally, a severe Kawasaki-like multisystem inflammatory syndrome rarely is seen in children. This diverse range of cutaneous manifestations in COVID-19 reflects a spectrum of host immunologic responses to SARS-CoV-2 and may inform disease pathophysiology.
Practice Points
- Cutaneous manifestations of COVID-19 may reflect the range of host immunologic responses to SARS-CoV-2.
- Perniosis appears to be a late manifestation of COVID-19 associated with a comparatively benign disease course, whereas livedoid or other vasculopathic lesions portend poorer outcomes and may warrant further workup for occult thrombotic disease.
- Maculopapular, vesicular, and urticarial eruptions may be seen in association with COVID-19 but are nonspecific and necessitate a broad differential and workup.
- Challenges posed by the COVID-19 pandemic necessitate creative management strategies for immunosuppression and clinical assessment.
Pandemic Dermatology
The pandemic has posed unprecedented challenges for patient care. The use of hydroxychloroquine as a popular but unproven treatment for COVID-19, 53 particularly early in the pandemic, has resulted in drug shortages for patients with lupus and other autoimmune skin diseases. Meanwhile, the need for patients with complex dermatologic conditions to receive systemic immunosuppression has had to be balanced against the associated risks during a global pandemic. To help dermatologists navigate this dilemma, various subspecialty groups have issued guidelines, including the COVID-19 Task Force of the Medical Dermatology Society and Society of Dermatology Hospitalists, which recommends a stepwise approach to shared decision-making with the goal of minimizing both the risk for disease flare and that of infection. The use of systemic steroids and rituximab, as well as the dose of immunosuppression—particularly broad-acting immunosuppression—should be limited where permitted. 54
Rapid adoption of telemedicine and remote monitoring strategies has enabled dermatologists to provide safe and timely care when in-person visits have not been possible, including for patients with confirmed or suspected COVID-19, as well as for hospitalized patients. 55-57 Use of telemedicine has facilitated preservation of personal protective equipment at a time when these important resources have been scarce. For patients with transportation or scheduling barriers, telemedicine has even expanded access to care.
However, this strategy cannot completely replace comprehensive in-person evaluation. Variability in video and photographic quality limits evaluation, while in-person physical examination can reveal subtle morphologic clues necessary for diagnosis. 5 8 Additionally, unequal access to technology may disadvantage some patients. For dermatologists to provide optimal care and continue to contribute accurate and insightful observations into COVID-19, it is essential to be physically present in the clinic and in the hospital when necessary, caring for patients in need of dermatologic expertise. Creative management strategies developed during this time will benefit patients and expand the reach of the specialty . 5 8
,Final Thoughts
The COVID-19 pandemic has profoundly challenged the medical community and dermatology is no exception. By documenting and characterizing the diverse cutaneous manifestations of this novel disease, dermatologists have furthered understanding of its pathophysiology and management. By adapting quickly and developing creative ways to deliver care, dermatologists have found ways to contribute, both large and small. As we take stock at this juncture of the pandemic, it is clear there remains much to learn. We hope dermatologists will continue to take an active role in meeting the challenges of this time.
