Public health

Pseudo-chilblains among 5 common skin manifestations of COVID‐19 disease


Five major patterns of cutaneous manifestations of COVID‐19 disease have been identified that may help in diagnosis of the condition and be a  guide to prognosis.

The clinical patterns were derived by dermatologists in Spain who assessed reports from 375 COVID-19 patients at the height of the epidemic in the country.

Following dermatologist review of images and clinical data they found that lesions could be classified in five groups:

  1. Pseudo-chilblain (19%): acral areas of erythema-oedema with some vesicles or pustules of cases. These lesions appear late in the evolution of the COVID-19 disease, may resemble chilblains and have purpuric areas, affecting hands and feet. They lasted for a mean of 12.7 days, were associated with less severe disease.
  2. Vesicular eruptions (9%): small monomorphic vesicle often on the trunk in middle aged patients. Usually seen before other symptoms and associated with intermedium severity. Itching was common (68%). They may also affect the limbs, have haemorrhagic content, and become larger or diffuse.
  3. Urticarial lesions (19%): mostly distributed in the trunk or disperse, occurred for shorter period (6.8 days) and were associated itch and with more severe COVID-19 disease.
  4. Maculopapular eruptions (47%): As with urticarial lesions, they had a shorter duration (8.6 days)  and were associated with more severe disease (2% mortality).
  5. Livedo or necrosis (6%): More often seen in older patients with more severe disease (10% mortality). Different degrees of lesions suggesting  occlusive vascular disease, including areas of truncal or acral ischemia.

Writing in the British Journal of Dermatology, the dermatologists said they hoped their description of clinical patterns would allow for easy classification of cutaneous manifestations of COVID-19 disease, and some might aid diagnosis of the disease in patients who otherwise had few symptoms.

However they noted that the most common manifestions – pseudo-chilblain and vesicular lesions commonly appear later during the disease and are not associated with severe disease, so they might be more useful as epidemiological markers.

The Australasian College of Dermatology has also produced a visual guide to the skin signs of COVID-19.

The College says that cutaneous manifestations have been seen in 20% of COVID-19 patients, and “a high suspicion for possible COVID-19 is recommended” if these signs are seen in patients.

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