Skin Manifestations in COVID-19 Patients: Are They Indicators for Disease Severity? A Systematic Review

Abstract

Introduction: Until now, there are several reports on cutaneous manifestations in COVID-19 patients. However, the link between skin manifestations and the severity of the disease remains debatable. We conducted a systematic review to evaluate the temporal relationship between different types of skin lesions and the severity of COVID-19.Methods: A systematic search was conducted for relevant studies published between January and July 2020 using Pubmed/Medline, Embase, and Web of knowledge. The following keywords were used: “SARS-CoV-2” or “COVID-19” or “new coronavirus” or “Wuhan Coronavirus” or “coronavirus disease 2019” and “skin disease” or “skin manifestation” or “cutaneous manifestation.”Results: Out of 381 articles, 47 meet the inclusion criteria and a total of 1,847 patients with confirmed COVID-19 were examined. The overall frequency of cutaneous manifestations in COVID-19 patients was 5.95%. The maculopapular rash was the main reported skin involvement (37.3%) commonly occurred in middle-aged females with intermediate severity of the disease. Forty-eight percentage of the patients had a mild, 32% a moderate, and 20% a severe COVID-19 disease. The mild disease was mainly correlated with chilblain-like and urticaria-like lesions and patients with vascular lesions experienced a more severe disease. Seventy-two percentage of patients with chilblain-like lesions improved without any medication. The overall mortality rate was 4.5%. Patients with vascular lesions had the highest mortality rate (18.2%) and patients with urticaria-like lesions had the lowest mortality rate (2.2%).Conclusion: The mere occurrence of skin manifestations in COVID-19 patients is not an indicator for the disease severity, and it highly depends on the type of skin lesions. Chilblain-like and vascular lesions are the ends of a spectrum in which from chilblain-like to vascular lesions, the severity of the disease increases, and the patient's prognosis worsens. Those with vascular lesions should also be considered as high-priority patients for further medical care.

Identification, Mechanism, and Treatment of Skin Lesions in COVID-19: A Review

“…Thus, skin lesions that precede general symptoms or are even the only sign of positive COVID-19 could serve as early indicators of disease or as indicators of asymptomatic carriers of the virus. In addition, some types of lesions precede the development of the more typical COVID-19 symptomatology and there is even evidence that some types of lesions lead to a worse prognosis and evolution of the disease [25]. This would make it easier therefore to predict a more serious or severe course of SARS-CoV-2 infection.…”

Bioinformatic analyses suggest augmented interleukin-17 signaling as the mechanism of COVID-19-associated herpes zoster

“…Emerging evidence supports that herpes zoster might be a cutaneous manifestation of COVID-19 (Brancaccio et al 2021 , Jamshidi et al 2021 ). In this regard, it has been postulated that COVID-19-associated immunosuppression (e.g., suppressed T cell-mediated immunity) or the psychological stress inflicted by the pandemic might promote VZV reactivation and thus account for the escalating number of herpes zoster cases (Pona et al 2020 ).…”

Patient Recovery from COVID-19 Infections: Follow-Up of Hair, Nail, and Cutaneous Manifestations

“…Maculopapular rash was frequently reported in moderate severity with good outcome. Retiform purpura was associated with more severe disease and worse prognosis [ 22 ]. However, from our study, urticaria and maculopapular rash could be observed in any severity of COVID-19 except asymptomatic and had 100% survival rate.…”