|Year : 2020 | Volume
| Issue : 4 | Page : 240-247
Dermatological manifestations in children and adults with COVID-19 infections
Abhilasha Williams1, Amrutha Dirisala2, Monika Sharma2
1 Department of Dermatology, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Paediatrics, Christian Medical College and Hospital, Ludhiana, Punjab, India
|Date of Submission||17-Jan-2021|
|Date of Decision||26-Jan-2021|
|Date of Acceptance||19-Feb-2021|
|Date of Web Publication||8-Apr-2021|
Department of Dermatology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
The cutaneous manifestations of COVID-19 infection are evolving rapidly as new data continue to be published in the literature. Considering that majority of these manifestations resemble other viral exanthemas, a high degree of suspicion and clinical acumen is needed for early identification of COVID-19 infections and its prompt management. The most common manifestations in adults include maculopapular rash, purpura, vesicular rash, urticarial rash, and pseudo-chilblains, while in children, the manifestations include Kawasaki disease-like inflammatory syndrome (pediatric inflammatory multisystem syndrome) and erythema multiforme. This review presents a comprehensive guide to the cutaneous manifestations of COVID-19 infections in adults and children. Also included are the dermatological manifestations observed due to prolonged use of personal protective equipment in healthcare workers.
Keywords: Chilblains, COVID-19 infection, erythema multiforme, pediatric inflammatory multisystem syndrome, personal protective equipment, viral exanthema
|How to cite this article:|
Williams A, Dirisala A, Sharma M. Dermatological manifestations in children and adults with COVID-19 infections. CHRISMED J Health Res 2020;7:240-7
|How to cite this URL:|
Williams A, Dirisala A, Sharma M. Dermatological manifestations in children and adults with COVID-19 infections. CHRISMED J Health Res [serial online] 2020 [cited 2021 Jun 24];7:240-7. Available from: https://www.cjhr.org/text.asp?2020/7/4/240/313178
| Introduction|| |
With the COVID-19 pandemic, the world has changed dramatically. Every person is affected one way or the other. The most common symptoms at presentation are usually fever, cough, fatigue, and myalgia. Severe cases more frequently report dyspnea and develop acute respiratory distress syndrome. It poses a health challenge for medical professionals including dermatologists.
The skin manifestations are uncommon and not characteristic. New data are being added to the medical literature daily and serve as a guide to manage this infection, based on the clinical experience of health professionals already dealing with this viral infection.
The WHO declared the COVID-19 infection a pandemic on March 11, 2020. As on May 7, 2020, the WHO has reported >3.5 million cases of COVID-19 and 250,000 deaths. It is a highly contagious infection.
The COVID-19 skin manifestations can be divided into those related to the viral infection and use of personal protective gear. This review is an attempt to describe the dermatological manifestations and complications of COVID-19 infection, with special emphasis on rare cutaneous findings in children which are emerging as more cases are being diagnosed worldwide.
Skin lesions of COVID-19 infection have not been classified till date. All the data available are based on case reports, case series, and case collection of surveys. As this pandemic continues to spread, it is prudent for the dermatologists and pediatricians to be aware of the manifestations of COVID-19 infection as documented by those who have had the experience while treating such patients in countries and states where this infection rate was very high. Healthcare workers who have yet to see a case of COVID-19 infection need to be aware of the symptoms and signs to be well prepared to diagnose this infection early and help in prompt diagnoses and management.
As per the data already published, there is no rash which is sensitive or specific to COVID-19 infection as of now to pin point to this infection. So far, all the cutaneous manifestations reported are commonly seen in other viral infections, especially parvovirus., Hence, it is safe to call it the New Great Imitator.
We have classified skin manifestations as follows:
- Those related to healthcare professionals using personal protective equipment (PPE)
- Those related to COVID-19 infection in adults and children.
Skin manifestations associated with wearing of personal protective equipment
It is important to preserve the skin barrier function to prevent the transmission/spread of this unprecedented viral infection. The PPE are gears designed to safe guard the health of workers by minimizing the exposure to a biological agent. It includes goggles, face shields, masks, gloves, coverall/gowns/aprons, and head and shoe covers. The skin lesions could be due to the hand cleaning, eye protection, nasal and oral mucosa protection, protection of the pinnae, glove, mask, and UV related.
Insufficient and excessive protection using any of these components of the PPE has many adverse effects on the skin and mucus membrane barrier. It has been documented that the mucous membranes are the main portal of entry for COVID-19 infection. Moreover, dermatological diseases with disrupted epidermal barrier could enhance the acquisition of this infection via indirect contact. Therefore, the dermatologists should be aware of the high risk of transmission of the infection in preexisting dermatological disorders and be able to take preventive measures and modify the management of the patient accordingly. Whether there is a vertical transmission from mother to child is not confirmed as yet.
The majority skin lesions are associated with hyperhydration effect of PPE, friction, contact reactions, and epidermal barrier disruption. A preexisting skin condition could also be aggravated due to these.
The most common manifestations of prolonged PPE wear are papules, erythema, maceration, and scaling. The nasal bridge is the most commonly affected site (83%) followed by the cheeks, forehead, and the hands. Most of the injuries reported are due to the use of goggles and not N95 masks. The symptoms of burning, stinging, and itching are noted in up to 97% of frontline healthcare workers. Pressure urticaria, contact dermatitis, and aggravation of preexisting dermatoses are reported to occur in patients with prolonged contact with masks and goggles. Elston reported acne, facial itching, and dermatitis following the use of N95 mask in one-third of the healthcare workers. The prolonged use of protective hats has been associated with exacerbation of seborrheic dermatitis and folliculitis, with pruritus being the most common symptom.
Skin manifestations due to prolonged use of gloves
Maceration and erosions are the most common manifestations which occur due to occlusion and hyperhydration state of the epidermis. End result is the development of contact dermatitis.
Skin manifestations related to personal hygiene measures
Frequent and prolonged hand washing with detergents and disinfectants disrupts the hydrolipid mantle of the skin surface, leading to irritation and development of contact dermatitis.
Elston found that although two-thirds of the healthcare workers wash hands over 10 times a day, only 22% use a skin protective cream leading to a higher incidence of hand dermatitis.
Some of the predisposing factors for the development and/or aggravation of hand dermatitis are atopic diathesis, low humidity, frequency of hand washing, wet work, glove use, and duration of employment. Recommendation for the prevention of contact dermatitis includes frequent application of hand creams, especially following hand washing and before wearing PPE. Doing a patch test with a low concentration of sodium lauryl sulfate can be used to predict those at a highest risk for developing hand dermatitis.
Some of the measures that could be taken to prevent such injuries would be to provide PPE equipment according to the proper size of the healthcare provider, e.g., goggles, and adequately moisturize the area of contact before wearing of the PPE. At the administrative level, shorter rotating shifts in high-intensity protective gear may reduce the incidence of the ulceration due to ill-fitting PPE. It is highly recommended to use moisturizing lotions for better protection.
Skin manifestations associated with COVID-19 infections
The most commonly associated skin lesions in COVID-19 patients noted worldwide are as follows: maculopapular rash, urticarial rash, pernio-like lesions including palmar erythema, petechial and purpuric rash, vesicular rash, livedo reticularis, and necrosis.
Galván Casas et al. have noted five distinctive clinical patterns namely acral areas, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis, while the other major study done by Recalcati have described erythematous rash, urticaria-like rash, and chicken pox-like rash as the main clinical patterns in their study population Sachdeva et al. have reported that the trunk is the most commonly involved site.
Erythematous maculopapular rash by far is the most common occurring skin manifestation described so far and generally appears along with the other systemic symptoms of COVID-19 infection [Figure 1]. The prevalence of this rash is between 15.9% and 475%., Galván Casas et al. also mentioned a perifollicular distribution of this rash with varying degrees of scaling and few lesions resembling the rash of pityriasis rosea. Other case reports with presentations of erythematous maculopapular rash are emerging. Najarian reported erythematous macules with islands of normal looking skin in between them arranged in a morbilliform pattern (measles-like). Sachdeva et al. reported an itchy erythematous maculopapular rash resembling Grover disease. Itching was noted in 57% of the cases.
Some patients also presented with varying degrees of purpuric rash. Joob and Wiwanitkit have described a rash which was mistaken for dengue rash. Diaz-Guimaraens et al. reported an exanthem rash with symmetric periflexural distribution affecting the buttocks, popliteal fossae, proximal anterior thighs, lower abdomen, and sparing the crural folds. Bilateral axillary purpuric eruptions were reported by Ahouach et al. similar to Jimenez-Cauhe et al., who also observed erythemato-purpuric millimetric macules on bilateral periaxillary areas. Punctiform purpura and macular hemorrhagic rash have also been reported.,
Marzano et al. have reported the first case series of 22 COVID-19 patients with varicella-like exanthema and have labeled this rash to be COVID-19-“associated specific picture. Here, the rash reported is constantly involving the trunk, associated with mild/absent pruritus. These lesions tended to appear 3 days after the systemic symptoms and resolved in 8 days. Healing occurred without scarring. Other studies have reported a prevalence of vesicular rash between 1.13% and 9%., Similarly, Galván Casas et al. too reported the trunk to be the most common site of involvement. However, they reported a higher prevalence of associated itching (68%). These vesicular lesions tended to be monomorphic rather than polymorphic as observed in varicella infection, and few bullae and hemorrhagic lesions were also reported. Preliminary data suggest that in 15% of the cases, the vesicular rash appears early in the course of the disease. Sachdeva et al. reported a patient with papulovesicular rash over the submammary folds, trunk, and hips.
Presence of monomorphic vesicles, absent or mild pruritus can give a clue to a dermatologist in favor of COVID-19 infection, as varicella is associated with polymorphic lesions and pruritus being a major symptom.
Urticarial lesions associated with COVID-19 infection have been documented by many authors., Galván Casas et al. observed urticarial lesions in 19% of the study population, mostly on the trunks and palms. They were associated with itching in 92% of the cases. Estébanez et al. noted pruritic lesions which were confluent erythematous-yellowish papules over the heels, which healed in about 10 days. Zhang et al. documented drug hypersensitivity in 11.4% and urticaria in 1.45 of the patients.
Galván Casas et al. describe acral erythema with vesicles and pustules (pseudo-chilblains) in 19% of their COVID-19 patients. Kolivras et al. have reported these lesions to be manifestation of COVID-19 infection which are more common over the toes, not associated with any previous history of chilblains in the past or collagen vascular disease or Raynaud phenomenon. It mostly manifests in children, adolescents, and young adults with a milder course of the disease. These findings match those of Casas et al. They report associated symptoms of pseudo-chilblains to be pain (32%) and itch (30%). They tend to appear late in the evolution of the infection in 59% of the patients, usually after other symptoms, and were mostly asymmetrical. Alramthan and Aldaraji have also reported finding of chilblain disease in a COVID-19 patient.
}The term “COVID Toes” is gaining popularity to describe these lesions worldwide.
The cutaneous manifestations in COVID-19 infection related to occlusion of the cutaneous vasculature by microthromboses originating in other organs are variable [Figure 2]. Many different types of skin lesions have been reported. Galván Casas et al. reported livedo or necrosis in 6% of their study cases. Some were truncal and acral in distribution. They were more common in the elderly patients. Rash resembling livedo reticularis and DIC can occur. Cutaneous mottling was observed in a neonate. Report of acral ischemic lesions is also published. Retiform purpura and unilateral transient livedo reticularis are other rare cutaneous findings observed in COVID-19 patients.
Other rare findings
Palmar erythema and enanthem are reported by Casas et al. Few lesions with infiltrated papules resembling erythema elevatum diutinum or erythema multiforme (EM) have also been reported. These lesions were observed most commonly over the dorsum of the hands. A rare presentation included a rash resembling symmetrical drug-related intertriginous and flexural exanthem.
| Cutaneous Manifestations of COVID-19 in Children|| |
The cutaneous manifestations of childhood COVID-19 differ from those of adults. While manifestations such as urticaria, maculopapular rash, or vesicular rash can occur in people of all ages, certain manifestations such as chilblains, EM, and cutaneous manifestations of pediatric inflammatory multisystem syndrome (PIMS) temporally associated with SARS-CoV-2 are more frequently seen in children and young patients.
| Chilblain-like Lesions|| |
Classic chilblains (pernio) are defined as inflammatory skin lesions of the acral regions that persist for >1 day. They are characterized by erythematous and edematous macules, nodules, and sometimes ulcerated plaques on the dorsal surface of fingers and toes.
The first published pediatric case of possible SARS-CoV-2 associated chilblain-like lesions occurred in Italy, followed by reports of similar cases from Italy, Spain, and the Middle East.,, Chilblain-like manifestations observed during the COVID-9 pandemic differ from classic pernio by showing an equal sex distribution, absence of triggering factors, and involvement of the feet and sometimes the distal third of the legs. In a Spanish consensus, “pseudo-chilblains” were reported in 19% of 375 patients with skin manifestations of COVID-19. In a French retrospective study on 277 patients with COVID-19, chilblain-like lesions were the most frequent cutaneous manifestation in a mix of confirmed or suspected cases.
The lesions usually occur in children and adolescents in good health; they are rarely seen in children younger than 10 years of age. They appear on the feet in 74%-“100% of the cases but have also been described on the hands and fingers.,, Unlike adult cases, in which 45% of the patients experienced COVID-19 symptoms, children/adolescents are usually asymptomatic, although local pain and itch may occur (ranging from 9.4% to 57.8% of cases).,, All children and adolescents published thus far had a favorable outcome with spontaneous regression of the lesions and no complications. Rarely, oral analgesics and antihistamines were administered.,, Oral gabapentin was used in one case for pain control. Steroids have been prescribed in cases with associated EM-like eruption.
| Erythema Multiforme|| |
EM is an acute, self-limiting hypersensitivity condition, which is characterized clinically by a distinctive skin eruption with symmetrical erythematous lesions called iris or target lesions., An EM-like eruption has been observed in association with SARS-CoV-2 infection, both in adults and in children., Children with EM in the setting of COVID-19 have been otherwise asymptomatic or have had only mild respiratory or gastrointestinal symptoms.
| Urticaria|| |
Urticaria presents with usually pruritic, circumscribed, raised wheals, which characteristically last <24 h. Urticaria represents about 10%-“20% of the cutaneous manifestations in patients with COVID-19.,
| Vesicular Exanthem|| |
There is no consensus regarding the definition of “COVID-19 vesicular rash.”,, Initially, the vesicular eruption reported in patients diagnosed with COVID-19 was a varicella-like papulovesicular rash. Vesicular lesions are thought to appear in the early stages of COVID-19 disease, and occasionally even before the onset of other manifestations,, compared with other skin manifestations occurring later. The eruption is monomorphic with disseminated vesicles, appearing after a median latency of 3 days after first respiratory symptoms and persisting for around 8 days with no correlation with severity of infection.,,, Vesicles predominate on the trunk, but the limbs may also be affected, and papular, crusted, or hemorrhagic lesions are also associated. Itch is common but is usually mild.
| Kawasaki Disease-like Inflammatory Syndrome (Pediatric Inflammatory Multisystem Syndrome)|| |
KD is the most common vasculitis in childhood, and its diagnosis is based on clinical and laboratory criteria., The role of a nonspecific infection, such as seasonal coronavirus, as a trigger factor is classically suggested.,,
According to the American Heart Association criteria of KD, a complete form of KD was found in 50%-“52% of cases and an incomplete form of the disease was seen in 48%-“50% of cases., The diagnosis of incomplete types was based on fever for >5 days plus two or three classic criteria, considering laboratory anomalies and/or abnormal echocardiography (coronary aneurysms, left ventricular depression, mitral valve regurgitation, pericardial effusion) as associated additional diagnostic criteria. Cutaneous and mucosal manifestations are common in PIMS.,, A nonexudative conjunctivitis was described in 50% of Italian patients with the complete form and 30% with the incomplete form and in 81% of French patients. A “polymorphic” rash was seen in 50% of Italian patients with the complete form and 30% with the incomplete form and in 76% and 20% of French patients with the complete and incomplete forms, respectively. Perineal or face desquamation was observed in 19% of French patients. Finally, hand and feet anomalies (erythema, firm induration or both) were described in 50% of Italian patients and 48% of French patients.
| Other Manifestations|| |
Several nonspecific viral exanthems have been attributed to SARS-CoV-2 [Figure 3]. Vasculopathic rashes including purpuric thrombocytopenic purpura. Dengue-like exanthema,, acro-ischemia, and livedoid eruptions, have been linked to COVID-19 in adults and occasionally in children as well.,
Oral mucosa findings have received little attention in all age groups. In a recent study performed in a field hospital in Spain, up to 25% of patients showed oral mucosa abnormalities, 18% of which had macroglossia and anterior papillitis. A 12-year-old girl with tongue swelling and prominent papillae with positive COVID-19 polymerase chain reaction test has been reported, further supporting the potential involvement of the oral cavity in patients with COVID-19.
| Preventive Measures for Healthcare Professionals|| |
Majority of the skin compilations are preventable, and therefore, all healthcare providers should take adequate preventive measures and abide by the recommendations which include frequent application of barrier creams and emollients before wearing of the PPE and after hand washing.
Occupational skin diseases among healthcare professionals are common and lead to days lost from work. They should be treated adequately and prevented as much as possible to increase productivity and efficacy in the work place.
A major concern for dermatologists is treatment of patients with autoimmune and chronic inflammatory disorders such as pemphigus, bullous pemphigoid, psoriasis, systemic lupus erythematosus, and atopic dermatitis who require immunosuppression. There are no clear-cut guidelines whether the immunosuppression dose should be reduced or completely stopped. Whether the biological therapy can be initiated or be delayed is still a big question.
It is important to keep the possibility of drug rash in mind, especially if the clinical pattern of maculopapular rash and urticaria is present. Since these presentations are common in other viral infections also, a strong clinical suspicion is required to reach a diagnosis.
| Take Home Message|| |
Of all the cutaneous manifestations described so far, the ones which could strongly indicate the disease would be the pseudo-chilblain and the vesicular rash. Since the pseudo-chilblain lesions occur primarily in healthy patients and later in the course of the disease, they are more helpful as an epidemiological marker rather than for the diagnosis.
It should be noted that as the literature regarding COVID-19 infection is currently evolving, at this point, the authors are unable to comment whether the skin manifestations are rare or uncommon because each day new data are being published. This review aims to increase awareness among dermatologists, pediatricians, and other healthcare workers who might not have a practical experience thus far. Knowledge is power, and this review presents with the information on the varied cutaneous manifestations of this unprecedented COVID-19 infection so that we are prepared to battle this infection in the light of medical evidence and experience of the healthcare professionals already fighting this invisible enemy of humanity.
| Conclusions|| |
There are multiple skin manifestations related to the COVID-19 pandemic which cannot be ignored. Apart from dermatologists, and pediatricians, other healthcare providers should be able to recognize these as many a times a dermatologist is unavailable or restriction of movement in COVID wards prevents easy consultation with a dermatologist.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]