Since February 2020, when coronavirus disease began to spread in Italy, general practitioners (GPs) were called to manage a growing number of health situations. The challenges experienced by Italian GPs remained unrevealed. This study aimed at exploring Italian GPs' care experiences and practices associated with critical incidents during the first wave of the pandemic. A qualitative study design involving the critical incident technique through an online survey was applied. Sociodemographic data and open-ended responses were collected. While participants' characteristics were analyzed through descriptive statistics, qualitative data were thematically analyzed employing the framework method. 149 GPs responded to the survey and 99 participants completed the survey (dropout rate = 33%). Eight themes emerged indicating factors related to the organization of the healthcare system and factors related to the clinical management of patients, that were perceived as impacting on the GPs' care provision. The analysis revealed difficulties in communicating with other local services. This, together with the lack of coordination among services, was reported as a major challenge. Primary care was perceived as having been undervalued and criticalities in the organization of GP courses, led in a bureaucratic fashion, posed at risk some trainees to be infected. The digital technologies adopted for remote patient consultations were seen as useful tools for daily practice helping the GPs to stay emotionally connected with their patients. Besides, the improvement in the GP–patient relationship in terms of solidarity between patients and doctors and compliance to rules, had a positive impact. Moreover, many respondents addressed the importance of professional collaboration and teamwork, in terms of both support in practical issues (to find PPE, diagnostics and guidelines) and emotional support. At the same time, the lack of resources (e.g., PPE, swabs) and of specific guidelines and protocols impacted on the care provision. Our findings suggest that GPs in Italy are at risk of being left behind within the epidemic management. Communication and coordination among services are essential and should be substantially improved, and primary care research should be initiated to collect the context-specific evidence necessary to enhance the system's preparedness to public health emergencies and the quality of primary care services.

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Background: the most commonly reported clinical manifestations of Coronavirus Disease (COVID- 19) are: fever, fatigue, dry cough, anorexia, myalgias, dyspnoea and sputum production. Other, rarer, manifestations include headache, sore throat, rhinorrhoea, nausea, diarrhoea and olfactory or taste disorders. Two recent small-scale studies suggest the possibility of a skin rash being a clinical presentation of the disease. The purpose of our case report is to bring attention to an atypical presentation of the disease (skin rash) and reflect on the importance of the correct identification of COVID-19 suspicious symptoms as part of the crucial activity of case-finding in primary care.Case presentation: the patient is an Italian 32 years old female nurse who has had several close contacts to COVID-19 cases during her working shifts. On the 13 th March 2020 she developed an itchy erythematous papular rash sparing only her sparing only her face, scalp and abdomen. One week later she developed fever and diarrhoea. During the first week of remote assessment carried out by her General Practitioner (GP), she gradually developed a dry cough, intermittent fever and diarrhoea. At the time of article submission (31 days after the symptoms onset), she has not completely recovered and is still suffering of a dry cough, headache, fatigue and, occasionally, diarrhoea.Conclusions: this study suggest that skin manifestations could be an early presentation of COVID-19 and, during outbreaks, they should be taken into proper account by primary care providers as possibly caused by Sars-Cov-2. Early identification of COVID-19 patients is a crucial part of the strategy of case detection and case isolation, which has shown to be crucial in the reduction of incidence and COVID-19-related mortality. Further research is needed to establish frequency, symptoms, signs, pathogenesis and role in case detection of skin manifestations in COVID-19 patients.