The novel coronavirus (SARS-CoV-2), the cause of coronavirus 2019 disease (COVID-19) pandemic, is associated with some cutaneous manifestations. Although the cutaneous presentations of COVID-19 are infrequent, it is of great importance for all clinicians to be aware of these manifestations, as it may contribute to sooner and better diagnosis and management of the disease, even in asymptomatic or paucisymptomatic patients. The reported cutaneous manifestations of COVID-19 are various, dispersed, and sometimes confusing. In this article, all reported cases to date were collected and classified under 6 major groups: maculopapular rash, urticaria, chilblain, vesicular lesions, livedo reticularis, and petechiae. Different characteristics of each group were discussed in detail as well.
On 31 December 2019, a newly emerged pneumonia caused by a novel coronavirus, named SARS-CoV-2, was announced by China [
PubMed and Cochrane were searched with the search terms “skin”, “cutaneous”, and “dermatology”, each in combination with “COVID-19” or “SARS-CoV-2”. All articles including case reports and original articles from the emergence of the disease (31 December 2019) to the submission of the article (9 May 2020) were included except for one article in which all 6 cases had neither positive PCR test nor common symptoms of COVID-19, and the authors presumed that their cutaneous manifestations may be related to SARS-CoV-2 without any documented evidence [
Different cutaneous lesions have been reported in 451 patients with COVID-19 to date (Table
Detailed characteristics of COVID-19 patients who developed cutaneous manifestations.
Cutaneous manifestation | Number of patients | Age (years) | Sex | Country | Localization of the skin lesions | Dermatological symptoms | Phase of COVID-19 in which skin lesions appeared | Clinical course of the skin lesions | Taking any medication before the appearance of skin lesions | Method of COVID-19 diagnosis |
---|---|---|---|---|---|---|---|---|---|---|
Maculopapular rash | 14 [ | N/M | N/M | Italy | Mainly trunk | Mild itching or asymptomatic | Active phase | Resolved few days later | N/M | All cases were confirmed by PCR. |
1 [ | 64 | F | France | Trunk & flexors | N/M | Active phase | Resolved 5 days later without any treatment | Paracetamol for 4 days (but the cutaneous lesions disappeared despite the drug was not discontinued) | PCR | |
1 [ | 59 | F | Italy | Trunk & limbs | N/M | Active phase in ICU | Resolved 5 days later without any treatment | N/M | PCR | |
1 [ | 89 | F | Italy | Trunk & limbs | N/M | Active phase in ICU | Resolved 8 days later without any treatment | N/M | PCR | |
1 [ | 57 | M | Italy | Generalized | Itching | Prodromal phase | Reduced 10 days later, after taking levofloxacin and hydroxychloroquine | N/M | PCR | |
2 [ | N/M | N/M | France | Face & upper body | Itching | Active phase | Resolved a few days later | N/M | Both cases were confirmed by PCR. | |
1 [ | 58 | M | USA | Trunk & extremities | Itching | Active phase | Began to improve 3 days later without any treatment | Azithromycin+benzonatate | PCR | |
1 [ | 20 | M | USA | Generalized, sparing the face | N/M | Active phase | N/M | N/M | PCR | |
1 [ | 6 | M | Thailand | Generalized | Itching | Active phase | Resolved 5 days later without any treatment | No medication | PCR | |
1 [ | 57 | F | France | Trunk & limbs | Asymptomatic except for burning sensation of palms | Active phase | Resolved 9 days later without any treatment | Paracetamol | PCR | |
176 [ | Mean age: 55.3 | F: 98 | Spain | N/M | Asymptomatic: 64 | Prodromal phase: 8 | Resolved few days later (mean: 8.6 days) | N/M | 122 cases were confirmed by PCR. Others were not tested. | |
Urticaria | 3 [ | N/M | N/M | Italy | Mainly trunk | Mild itching or asymptomatic | Active phase | Resolved few days later | N/M | PCR |
1 [ | 32 | F | Spain | Generalized | Itching | Active phase | Resolved 5 days later after taking antihistamines | Azithromycin+hydroquinone | N/M | |
1 [ | 27 | F | France | Face & acral parts | Itching | Prodromal phase | Slow improvement after taking antihistamines | No medication | PCR | |
2 [ | N/M | N/M | France | Face & upper body | Itching | Active phase: 1 | Resolved a few days later | N/M | Both cases were confirmed by PCR. | |
1 [ | 71 | M | Belgium | Generalized | Asymptomatic | Active phase | Resolved a few days later after taking bilastine | No new medication | All cases were confirmed by PCR. | |
1 [ | 39 | F | Belgium | Generalized | Itching | Active phase | Resolved a few days later after taking bilastine | No medication | N/M | |
1 [ | 2 months | F | Thailand | Generalized except for palms & soles | Itching | Active phase | Resolved 9 days later without any treatment | No medication | PCR | |
1 [ | 37 | F | Italy | Trunk, neck & face | Asymptomatic | Active phase (10th postpartum day) | Resolved 8 days later without any treatment | Acetaminophen | N/M | |
73 [ | Mean age: 48.7 | F: 47 | Spain | N/M | Asymptomatic: 4 | Prodromal phase: 3 | Resolved few days later (mean: 12.7 days) | N/M | 49 cases were confirmed by PCR. Others were not tested. | |
Chilblain | 1 [ | 27 | F | Kuwait | Dorsal aspect of fingers | Asymptomatic | Asymptomatic for COVID-19 | N/M | No medication/no exposure to cold | PCR |
1 [ | 35 | F | Kuwait | Dorsal aspect of fingers | Asymptomatic | Asymptomatic for COVID-19 | N/M | No medication/no exposure to cold | PCR | |
3 [ | 14-22 | N/M | France | Toes of both feet | Pain and burning | Asymptomatic for COVID-19 | N/M | No medication/no exposure to cold | Not tested | |
1 [ | 28 | F | Spain | Both heels | Itching | Active phase | N/M | No medication/no exposure to cold | N/M | |
1 [ | 26 | M | Italy | Both heels | Asymptomatic | Asymptomatic for COVID-19 | N/M | No medication/no exposure to cold | Not tested | |
1 [ | 16 | F | Italy | Both heels | Asymptomatic | Asymptomatic for COVID-19 except for pharyngodynia 2 weeks ago | N/M | No medication/no exposure to cold | Not tested | |
1 [ | 18 | F | Italy | Both heels & extensor surfaces of toes | Asymptomatic | Asymptomatic for COVID-19 | N/M | No medication/no exposure to cold | Not tested | |
1 [ | 48 | M | Italy | Extensor surfaces of both heels | N/M | Active phase | N/M | No medication/no exposure to cold | Not tested | |
Vesicular rash | 22 [ | M (16 cases) | Italy | All had truncal lesions ± involvement of extremities | Mild itching in 9 cases | Active phase | Resolved 4-15 days later | No medication | All cases were confirmed by PCR. | |
1 [ | N/M | N/M | Italy | Mainly trunk | N/M | Active phase | Resolved few days later | N/M | PCR | |
1 [ | 8 | F | Italy | Trunk | Asymptomatic | Active phase | Resolved 7 days later without any treatment | No medication | PCR | |
2 [ | N/M | N/M | Italy | Trunk (localized herpetiform) | Mild itching | Active phase | N/M | N/M | N/M | |
1 [ | N/M | N/M | Spain | Back (localized herpetiform) | N/M | Active phase | N/M | N/M | N/M | |
34 [ | Mean: 45.6 | F: 19 | Spain | N/M | Asymptomatic: 6 | Prodromal phase: 5 | Resolved few days later (mean: 9.3 days) | N/M | 17 cases were confirmed by PCR. Others were not tested. | |
Livedo reticularis | 1 [ | 67 | M | USA | Anterior thigh | Asymptomatic | Active phase | Resolved 19 hours later without any treatment | N/M | PCR |
1 [ | 47 | F | USA | Right lower limb | Asymptomatic | Convalescence phase | Resolved 20 minutes later without any treatment | No medication but appeared after sun exposure | PCR | |
21 [ | Mean age: 63.1 | F: 10 | Spain | N/M | Asymptomatic: 15 | Prodromal phase: 1 | Resolved few days later (mean: 9.4 days) | N/M | 17 cases were confirmed by PCR. Others were not tested. | |
Petechiae | 1 [ | N/M | N/M | Thailand | N/M | N/M | Prodromal phase | N/M | N/M | PCR |
1 [ | 48 | M | Spain | Buttocks, popliteal fossa, proximal anterior thighs, lower abdomen | Itching | Active phase | Resolved 5 days later with 0.05% betamethasone cream+loratadine | No new medication | PCR |
M: male; F: female; N/M: not mentioned; PCR: polymerase chain reaction; ICU: intensive care unit.
Although the cutaneous presentations of COVID-19 are various, they could be categorized in 6 major groups (Tables
Classification and characteristics of the cutaneous lesions reported in association with COVID-19.
Cutaneous manifestation (total number of reported cases) | Number of patients | Age, mean (range) (years) | Sex | Country | Location of skin lesions | Dermatologic symptoms | Phase of COVID-19 in which skin lesions appeared | Method of COVID-19 diagnosis |
---|---|---|---|---|---|---|---|---|
Maculopapular rash | 200 | 60.6 (6-89) | F: 102 | Spain: 176 | Trunk: 14 | Asymptomatic: 64 | Prodromal: 9 | 146 cases were confirmed by PCR. Others were not tested or N/M. |
Urticaria | 84 | 47.6 (2 months–71 years) | F: 52 | Spain: 74 | Trunk: 3 | Asymptomatic: 9 | Prodromal: 5 | 57 cases were confirmed by PCR. Others were not tested or N/M. |
Chilblain | 81 | 31.76 (14-48) | F: 53 | Spain: 72 | Fingers: 2 | Asymptomatic: 24 | Prodromal: 5 | 31 cases were confirmed by PCR. Others were not tested or N/M. |
Vesicular rash | 61 | Not reportable | F: 26 | Spain: 26 | Trunk: 26 (2 of them localized & herpetiform) | Asymptomatic: 20 | Prodromal: 5 | 41 cases were confirmed by PCR. Others were not tested or N/M. |
Livedo reticularis | 23 | 62.5 | F: 11 | Spain: 21 | Lower limb: 2 (unilateral) | Asymptomatic: 17 | Prodromal: 1 | 19 cases were confirmed by PCR. Others were not tested or N/M. |
Petechiae | 2 | 1 patient: 48 | M: 1 | Spain: 1 | Lower half of the body: 1 | N/M | Prodromal: 1 | Both cases were confirmed by PCR. |
M: male; F: female; N/M: not mentioned; PCR: polymerase chain reaction.
As it may be noticed, cutaneous lesions of COVID-19 may manifest in different forms, in every age and sex, and involve every part of the body. However, the involvement of mucosa has not been reported yet, except for a case of oral herpes simplex virus-1 reactivation in an intubated patient, which seemed to be secondary to the intubation rather than a presentation of the virus [
Although these data do not prove that COVID-19 was the definite cause of these skin lesions, they demonstrate that cutaneous lesions should be considered in the spectrum of presentations potentially associated with this infection. In particular, some cutaneous manifestations such as chilblain without any explanation may warn about asymptomatic virus carriers. However, further investigations should be carried out to evaluate the relation between skin lesions and COVID-19.
The authors declare that they have no conflicts of interest.