Brigham and Women's Hospitals

Dermatology

Updated May 11, 2020

Epidemiology

  1. Data collection:
  1. Please report cases at aad.org/covidregistry
  1. Incidence of rash, total
  1. Earliest data out of China with rash in 0.2% of patients, without morphologic description (Guan et al., N Engl J Med, 2020).
  2. Later data from Italy collected by dermatologists on the front lines showed rash in 18/88 patients (20.4%), excluding patients on new drugs (Recalcati. J Eur Acad Dermatol Venereol, 2020).
  1. Erythematous rash (n=14), urticaria (n=3), vesicles (n=1)
  1. Incidence of rash morphology and associations
  1. Spain cohort - 375 cases of rashes suspected to be COVID related, Limitation that patients had to consent, so more severe disease is less represented. (Galvan Casas et al., Br J Dermatol, 2020).
  1. 47% with “other maculopapules” including perifollicular lesions, pityriasis rosea-like lesions, non-palpable purpura and palpable purpura. Lesions lasted for a mean of 8.6 days, and appeared with the onset of other symptoms. Associated with more severe disease (2% mortality)
  2. 19% of cases with pseudo-Chilblains (“COVID toes”) Typically appearing in younger patients. Lesions lasted for a mean of 12.7 days and were found later in the course of disease. Associated with less severe disease
  3. 19% with urticaria. Lesions lasted for a mean of 6.8 days, and appeared with the onset of other symptoms. Associated with more severe disease (2% mortality)
  4. 9% with vesicular eruption. Middle-aged patients. Lesions lasted for a mean of 10.4 days, and appeared before other symptoms. Associated with intermediate severity.
  5. 6% with livedo/necrosis. Found in older patients with most severe disease (10% mortality)

Perniosis and Pseudo-Chillblains (“COVID toes”)

  1. Pathophysiology
  1. Cutaneous eruption secondary to systemic consequences caused by COVID
  2. Many mechanisms proposed given varying clinical appearance of acral lesions but likely due to Type I interferon-mediated complement activation and resultant microangiopathy (Kolivras, JAAD Case Reports, 2020)
  1. Clinical Presentation
  1. Clinically presents as erythematous to violaceous papules over acral surfaces (usually the fingers and toes, less commonly the nose and ears) following exposure to cold (fittingly called “acrocyanosis”)
  2. Lesions are invariably symptomatic, which could include pain, pruritus, or paresthesias
  3. Blistering, crusting, and ulceration can occur in severe cases
  4. Perniosis may be accompanied by livedo-like changes in adjacent skin
  5. Generally self-resolving however recurrence is possible with repeated cold exposure
  1. Work Up/ Diagnostics
  1. Many cases of perniosis have been associated with younger patients, a more benign prognosis, and often negative viral testing. Therefore, the work-up should be adjusted to the clinical setting and patient, taking into account the risks of viral transmission when patients travel to an outpatient lab. In many cases of perniosis without other clinical manifestations, further work-up is unnecessary and overly aggressive. The following could be considered with severe perniosis or associated livedoid changes. As proposed by Dr. Lindy Fox and others at the University of California, San Francisco.
  1. COVID-19 PCR swab
  2. COVID-19 IgM/IgG
  3. CBC with differential
  4. ANA
  5. RF
  6. Cold agglutinins
  7. Cryoglobulins
  8. C3, C4, CH50
  9. CRP, ESR
  10. D-dimer
  11. Fibrinogen
  12. Antiphospholipid antibodies
  1. Treatment
  1. No data to guide treatment
  2. Generally self-limited and on average, resolves within 1-2 weeks (Fernandez-Nieto et al, JAAD, 2020) (Mazzatto et al, Dermatologia Pediatrica, 2020)
  3. Can attempt treating as classic pernio for symptomatic relief with conservative measures (avoiding cold exposure, wearing socks, smoking cessation), aspirin for a possible vasculopathic etiology (with caution in the pediatric population given the risk of Reye’s syndrome), topical steroids, pentoxifylline, hydroxychloroquine, and calcium channel blockers.

Morbilliform Eruptions and Macular Erythema

  1. Pathophysiology
  1. Viral exanthem: immune response to viral antigens
  2. Drug eruption: type IV drug hypersensitivity reaction typically 4-14 days after start of new medication. For COVID therapies, it has been primarily reported with azithromycin, Lopinavir/ritonavir, and less commonly antimalarials (Suchonwanit et al., JAAD, 2020)
  1. Clinical Presentation
  1. Pink-red macules and papules (morbilliform means “measles”-like) that most often arise on the trunk and then spread to extremities symmetrically
  2. In severe cases, greater than 90% body surface area can be involved, referred to as erythroderma
  3. Generally pruritic however can be asymptomatic
  4. May assume a more violaceous/ purpuric component, notably in patients who are thrombocytopenic and may “bleed into the rash”
  5. Can be accompanied by fevers and peripheral eosinophilia. Persistent fevers and eosinophilia, facial involvement and swelling, diffuse sterile pustules, acute kidney injury, chest pain, and transaminitis are all concerning associated findings for a more severe drug reaction such as DRESS (drug reaction with eosinophilia and systemic symptoms) or AGEP (acute generalized exanthematous pustulosis)
  6. Most of these rashes resolve with darkening of the skin followed by desquamation
  1. Work Up/ Diagnostics
  1. Consider a broader differential diagnosis, as this clinical presentation is much more suggestive of other dermatologic entities or drug hypersensitivities.
  2. As with most drug eruptions, basic work-up should include a CBC with differential as well as renal and liver function panels. Physical exam warning signs of severe drug eruptions should be evaluated as well, including mucosal involvement or vesiculobullous lesions.
  3. Consider teledermatology consultation if the rash is new and not explained by other etiology.
  4. At this time, we do not recommend routine testing for SARS-CoV-2 based on the eruption of a new maculopapular rash. Decisions regarding testing for COVID-19 via PCR swab and/or COVID IgM/IgG should be based on other signs and symptoms of the patient presentation.
  1. Treatment
  1. Similar to classic morbilliform eruption with topical corticosteroids for symptomatic control of pruritus (Najarian, JAAD Case Rep, 2020). For the face, groin, and axillae, low-potency corticosteroids can be used. For the trunk and extremities, mid- to high-potency corticosteroids can be used. In general, topical corticosteroids should be used for no more than twice a day for 2 weeks at a time followed by a 2 week break.
  2. If a more severe drug reaction is suspected, dermatology consultation is appropriate for consideration of systemic therapies.

Urticaria

  1. Pathophysiology
  1. Immune response to viral antigens or drug haptens
  2. IgE-mediated immediate Type I hypersensitivity reaction
  3. It has been reported with antimalarials, though less common (Suchonwanit et al., JAAD, 2020)
  1. Clinical Presentation
  1. Present as edematous, erythematous papules or plaques often with central pallor
  2. Collectively referred to as hives or “wheals”
  3. Generally sharply demarcated and pruritic
  4. Urticaria are transient skin lesions and individual lesions should last less than 24 hours. New lesions may arise in other areas of the skin as prior lesions resolve
  5. Can occur on any site of the body, however the trunk is most commonly involved
  1. Work Up/ Diagnostics
  1. Consider a broader differential diagnosis, as this clinical presentation is much more suggestive of other dermatologic entities.
  2. Consider teledermatology consultation if the rash is new and not explained by other etiology.
  3. At this time, we do not recommend routine testing for SARS-CoV-2 based on eruption of a new urticarial rash. Decisions regarding testing for COVID-19 via PCR swab and/or COVID IgM/IgG should be based on other signs and symptoms of the patient presentation.
  1. Treatment
  1. Similar to classic urticaria with antihistamines (Quintana-Castanedo et al, JAAD Case Rep, 2020) (Henry et al, J Eur Acad Dermatol Venereol, 2020) (van Damme, J Eur Acad Dermatol Venereol, 2020) (Rivera-Oyola et al, JAAD Case Rep, 2020)

Vasculopathies, Livedo

  1. Pathophysiology
  1. Cutaneous eruption secondary to systemic consequences caused by COVID
  2. The end result of vascular occlusion ranging from superficial microthrombi to occlusive arterial thrombi within the deeper dermis. As with “COVID toes”, it may be secondary to complement activation or endothelial cell dysfunction and endotheliitis from viral inclusions vs. widespread systemic coagulopathy in more severe disease
  1. Clinical Presentation
  1. Livedo refers to a vascular reaction pattern that manifests as “mottling” of the skin, manifesting as a net-like/ reticular discoloration of the skin on the trunk and extremities
  1. When the findings are symmetric and continuous, referred to as livedo reticularis
  2. When the findings are asymmetric and discontinuous, referred to as livedo racemosa
  1. Livedoid vasculopathy/ vasculitis presents with usually tender purpuric macules or papules on the lower extremities
  1. The borders are generally angulated or retiform
  2. Heal with depressed, atrophic, white or ivory-colored scars
  1. Initial studies from New York have suggested that buttock predominant vasculopathic skin changes may be associated with poorer prognosis or more severe disease, however data on this is pending and anecdotal at this time.
  1. Work Up/ Diagnostics
  1. The initial workup can include the following, adjusted to the appropriate clinical setting. As proposed by Dr. Lindy Fox and others at the University of California, San Francisco.
  1. COVID-19 PCR swab
  2. COVID-19 IgM/IgG
  3. CBC with differential
  4. ANA
  5. RF
  6. Cold agglutinins
  7. Cryoglobulins
  8. C3, C4, CH50
  9. CRP, ESR
  10. D-dimer
  11. Fibrinogen
  12. Antiphospholipid antibodies (including anticardiolipin IgM/IgG, anti-β2-glycoprotein I IgM/IgG, and lupus anticoagulant, although these may be elevated with acute infection and require confirmatory repeat testing in ≥12 weeks)
  1. In addition, more complete thrombophilia work-up could be considered for select cases to rule out other causes if an alternative etiology to COVID-19 is suspected, including proteins C and S, homocysteine levels, Factor V Leiden, prothrombin gene mutation, and plasminogen activating factor-1 gene mutation (Vasudevan et al, Indian Journal of Dermatology, Venereology, and Leprology, 2016).
  1. Treatment
  1. Livedo reticularis
  1. Few cases of transient symptoms not requiring treatment (Manalo et al, JAAD, 2020)
  2. If persistent and with concern for potential ischemia/necrosis, could consider treatment with therapeutic anticoagulation as below
  1. Livedo racemosa/necrosis/gangrene
  1. Consider therapeutic anticoagulation while weighing risks of bleeding with continued thrombosis (Zhang et al, Zhonghua Xue Ye Xue Za Zhi, 2020) (Bellosta, J Vasc Surg, 2020)

Vesicular Eruptions

  1. Pathophysiology
  1. Viral exanthem: immune response to viral antigens
  1. Clinical Presentation
  1. Vesicles refer to small fluid-filled skin lesions (< 1 cm). Lesions larger than 1 cm are referred to as bullae.
  2. May be localized or diffuse
  1. Work Up/ Diagnostics
  1. Consider a broader differential diagnosis, as this clinical presentation is much more suggestive of other dermatologic entities, including other viral infections, autoimmune conditions, and drug reactions. For new vesiculobullous eruptions, consider development of a possibly severe drug reaction.
  2. Consider teledermatology consultation if the rash is new and not explained by other etiology.
  3. At this time, we do not recommend routine testing for SARS-CoV-2 based on eruption of a new vesicular rash. Decisions regarding testing for COVID-19 via PCR swab and/or COVID IgM/IgG should be based on other signs and symptoms of the patient presentation.
  1. Treatment
  1. Minimal data but reported to be self-limited with resolution in about 7 days (Genovese et al, Pediatr Dermatol, 2020)

Pressure Injuries

  1. Clinical presentation
  1. Can have a variety of clinical presentations including erythema, skin breakdown, ulcerations, gangrene, or frank necrosis
  2. Highest risk areas include sites of repeated pressure. In the context of COVID-19 and proning, facial pressure injuries have frequently been reported.
  1. Treatment
  1. Avoiding pressure injury
  1. Minimize pressure over bony prominences and face with dressings. Massachusetts General Hospital recommends the application of foam dressings to the upper chest/clavicles, shoulders, pelvis, elbows, knees, forehead, and dorsal feet. Gel pads may be used under the cheeks/nose (MGH, 2020)
  2. Turn the head and reposition arms every 2 hours.
  3. Frequently assess for blanchable erythema, an early sign of pressure injury

Outpatient Dermatology During COVID-19

  1. Management of suspected skin cancer in the ambulatory setting (NCCN Covid Resources)
  1. If skin cancer suspected, high resolution photograph should be taken and dermatology telemedicine referral placed
  2. Melanoma
  1. Suspected melanoma should be seen for biopsy
  2. Can defer surgery for thin melanomas (MIS, T1) for up to 3 months
  3. Can defer surveillance for patients with completely resected melanoma for up to 6 months
  1. Keratinocyte carcinomas (Squamous Cell Carcinoma, Basal Cell Carcinoma)
  1. Dermatologist will determine whether patient should be seen for biopsy
  2. Can defer surgery for keratinocyte carcinomas indefinitely unless patient at high risk for metastases or disability from untreated tumor (immunocompromised, history of CLL, lip / ear location, arising in a burn, >2cm)
  1. Skin conditions that warrant referral for in-person evaluation (Medical Dermatology Society Guidelines)
  1. Rashes
  1. Blistering rash (including but not limited to, concern for herpes or shingles)
  2. Painful skin
  3. Skin eruption involving eyes/mucosa
  4. Purpura, angulated (retiform) purpura, concern for vasculitis
  5. Diffuse pustular eruption
  6. Erythroderma (erythema >80% BSA)
  7. Diffuse itchy rash, interfering with sleep
  8. Infections (i.e. an infected wound, infected groin, worsening malodor, pus, reddening of the surrounding skin, fever) that cannot be managed remotely
  9. Diffuse rash with facial involvement and fever
  10. Severe drug reaction
  11. Immunosuppressed patients: new rash
  12. Some cases of severe eczema flare, worsening despite using topical/current therapy
  13. Some cases of severe psoriasis flare, worsening despite using topical/current therapy
  1. Lesions / tumors
  1. Changing pigmented mole/concern for melanoma
  2. Spontaneously bleeding lesion
  3. Immunosuppressed patients: concern for infection or skin lesion