When Covid-19 began to spread across the United States earlier this year, dermatology offices began to see suspicious signs on some patients’ skin: red or purple toes, itchy hives, spotted bumps on the fingers, a pointed red rash that spreads across the legs and arms.
But were they really associated with the new coronavirus? After all, many other factors can be at stake.
Many viral infections can trigger skin rashes, so when cataloging these case reports, you need to have other information. Was the patient on medication a week before the rash started? Are there other possible causes? asked Dr. Art Papier, associate professor of dermatology at the University of Rochester Medical Center in New York.
“This is the challenge that Covid-1
Case reports began to appear in medical journals. The latest, published Wednesday in the journal JAMA Dermatology, describes the experiences of four patients with severe Covid-19 who were hospitalized in New York in March and April.
The patients, aged 40 to 80, had discoloration of their skin as well as lesions called retiform purpura, according to the research report.
Biopsies were performed for each patient and they showed that the patients had a type of vasculopathy, which means that their blood vessels were affected.
The researchers – from New York-Presbyterian / Weill Cornell Medical College – wrote in their report that the discoloration of the skin could represent partial occlusion or blockage of blood vessels, and the retiform purpura may represent full blockage.
Such rashes and discoloration of the skin can be a “clinical clue” because there may be blood clotting in the body, the study says. Since early in the pandemic, doctors have noticed that severe Covid-19 can cause abnormal blood clotting in patients.
The report has some limitations, including that the researchers could not confirm the exact time when the rash and other skin problems first appeared for each patient. More research is also needed to determine if similar results would occur among a larger group of Covid-19 patients.
But overall, the researchers wrote in their report that doctors caring for Covid-19 patients should be aware of skin discoloration and rashes as “potential manifestations” of abnormal underlying blood coagulation.
“Many viral infections can affect the skin”
Doctors and researchers from around the world have also reported other types of skin rashes among Covid-19 patients.
Covid-19 often triggers significant inflammation in its victims, in some cases producing the so-called cytokine storm that seems to cause the worst damage in advanced patients.
The skin is particularly sensitive to inflammation, says the board’s certified dermatologist Dr. Seemal Desai, a spokesman for the American Academy of Dermatology.
“The cytokines that invade the immune motor in the car are what then trigger a variety of these immune molecules to enter the skin and cause damage to the skin,” says Desai, a dermatologist in Plano, Texas.
In July, researchers from King’s College London in the UK demanded that skin rashes and “Covid fingers and toes” be considered a major symptom of Covid-19, and even claim that they can occur in the absence of other symptoms.
Important symptoms of coronavirus that are widely accepted include fever, cough and shortness of breath, but a number of other signs have been suggested. The loss of smell and taste, another outlier, was recently included in the list of the most common symptoms by the US Centers for Disease Control and Prevention.
Kings College researchers used data from the Covid-19 Symptom Study app, which is submitted by about 336,000 people in the UK. They found that 8.8% of people who tested positive for coronavirus reported a skin rash as a symptom, compared with 5.4% of people who tested negative.
The KLC team then set up a separate online survey that collected information from nearly 12,000 people with skin rashes and suspected or confirmed Covid-19. The researchers found that 17% of respondents who tested positive for coronavirus reported a rash as the first symptom of the disease. For 21% of the people who reported a rash and had confirmed Covid-19, the rash was their only symptom.
The researchers reported their results in a pre-print study sent to the online server with RXiv.org. The results have not yet been published in a peer-reviewed journal.
“Many viral infections can affect the skin, so it is not surprising that we see these rashes in Covid-19,” Dr. Veronique Bataille, a dermatologist consultant at St Thomas’ Hospital and King’s College London, who was involved in the repression study, said in a press release in July.
“However, it is important for people to know that in some cases, a rash may be the first or only symptom of the disease,” Bataille said. “So if you notice a new rash, you should take it seriously by self-isolating and testing as soon as possible.”
Measure-like rash and rash in the mouth
Preliminary research has suggested that skin rashes and lesions in the mouth may be a symptom of coronavirus infection – but researchers say more study is needed.
In May, researchers around the world conducted a literature review and found that patients also presented with red, itchy rollers and with a red or pink rash that looked a lot like measles.
“It’s a reaction that we usually call morbilliform which means measles, which presents in kind of pink spots, lots of small pink spots all over the skin,” said Papier, the dermatologist at the University of Rochester Medical Center.
Another study published in JAMA Dermatology in July, found that among 21 patients in Spain who were confirmed to have Covid-19 and skin rashes, six of these patients or 29% had enanthema, or lesions or rashes in the mouth.
The average time between the onset of Covid-19 symptoms and the development of enantema was about 12 days among patients, according to researchers from Hospital Universitario Ramon y Cajal in Madrid.
“This work describes preliminary observations and is limited by the small number of cases and the absence of a control group,” the researchers wrote, adding that their results still suggest that enantema is a possible Covid-19 symptom and not a reaction to medications, for example.
“Despite the increasing reports of skin rashes in patients with COVID-19, it is challenging to establish an etiological diagnosis,” the researchers wrote. “But the presence of enanthema is a strong clue that suggests a viral etiology rather than a drug reaction.”
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