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COVID-19 dermatologic profile begins to emerge

While what is known about COVID-19 and dermatology is still evolving, dermatologists are amassing and analyzing a lot of information. What is emerging is a larger picture and some evidence of patterns, based on evidence collected thus far.

Headshot of Dr. Ko
Christine Ko, MD
Christine Ko, MD, professor of dermatology and pathology at Yale School of Medicine, presented a summary of the latest collective information through the end of April 2020, along with images from the literature in her AAD VMX presentation “What’s New In Dermatopathology: COVID-19 histopathologic findings.”

“Because of the desire for rapid dissemination of information, many articles have been published online ahead of print,” Dr. Ko said. “Initial dermatology-related literature has been case reports and some larger series. Not all of the cases were confirmed with serologic testing and many patients did not have biopsies due to efforts to protect our health care workers.”

Dr. Ko also talked about the largest study through the end of April, a nationwide study in Spain, with lead author C. Galván Casas, MD, that involved 375 cases of skin conditions in COVID suspected and confirmed patients.

Dr. Casas and his coauthors emphasized some major patterns that emerged throughout the course of the disease.

Early manifestations included vesicular lesions corresponding to dyskeratotic cells and interface change. Throughout the course of the disease, livedoid to purpuric skin findings correlating to vascular occlusion have been observed. Other skin findings concurrent with active COVID-19 infection included maculopapular and urticarial manifestations, and some of these could be due to drug hypersensitivity rather than a direct manifestation of Sars-CoV2 infection of the skin. Manifestations that are generally later in the course, sometimes in asymptomatic individuals, have included pernio- or chilblain-like lesions, which have come to be called “COVID toes,” although it can also involve the fingers, and the exact relationship to Sars-CoV2 infection is unclear.

Image for derm manifestations of covid-19 in vmx news
Superficial and deep perivascular infiltrate of relatively tightly cuffed lymphocytes.

In an exclusive interview with Dermatology World, Dr. Ko answered more questions about COVID-19 and dermatology.

Dermatology World: So far, we’ve seen fever, cough, and loss of taste or smell serve as possible predictors of COVID. Might skin conditions and the patterns you outlined eventually be used to help predict COVID?

Dr. Ko: I think the literature that is out there right now suggests that chicken pox-like vesicular lesions on the trunk are most important to look out for, in terms of active, early infection. Usually this type of rash is in someone who already has constitutional symptoms.

DW: Are you seeing anything that suggests conditions persist beyond COVID? Do the conditions go away when the disease goes away?

Dr. Ko: I don’t think we fully know the answer to this. There is the pediatric multi-inflammatory syndrome, where definitely problems may persist in different organ systems. It is thought to be COVID-related, but we need more information.

DW: What is being suggested for patients who have these skin conditions that are being associated with COVID?

Dr. Ko: People should get tested and self-isolate if they have general symptoms and the kind of truncal rash I’ve described. The COVID toes or fingers are thought to suggest the tail-end of infection, or perhaps some kind of post-viral immunologic reaction. If we discover that having had COVID will mean that you will not get it again, the significance of COVID toes/fingers may be a positive sign that you were exposed and may now be protected immunologically. However, we don’t know that to be true yet.

Derm manifestations of covid-19 for vmx news
Slightly edematous, reddish plaques on the dorsal finger. Image courtesy of Robert Patrignelli, MD.

DW: As you began to observe the dermatologic conditions that are emerging with COVID-19, did you notice anything interesting about the patterns?

Dr. Ko: Patients seem to have a tendency to developing clots, in small vessels as well as larger vessels, sometimes not immediately during the peak of active symptoms.

DW: Do you expect we will learn a lot more, as more data comes in?

Dr. Ko: We would benefit from knowing a lot more. Some things are true — for example, older individuals and patients who are diabetic are at higher risk for more severe disease. However, we still don’t fully know why some people get so much sicker than others, although there may be a strong relationship to the immunologic response that adults and children mount.

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