Version May 2024
INTRODUCTION — Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), raises many critical issues in dermatology and dermatologic care. Addressing these issues is necessary, yet also challenging, because there are few direct data on which to base recommendations [1].
This topic will discuss issues related to dermatologic care during the COVID-19 pandemic. Other relevant aspects of SARS-CoV-2 infection and patient management are discussed in detail separately.
●(See "COVID-19: Epidemiology, virology, and prevention".)
●(See "COVID-19: Clinical features".)
●(See "COVID-19: Diagnosis".)
●(See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)
●(See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Management of adults with acute illness in the outpatient setting".)
●(See "COVID-19: Hypercoagulability".)
●(See "COVID-19: Management in hospitalized adults".)
●(See "COVID-19: Considerations in patients with cancer".)
●(See "COVID-19: Care of adult patients with systemic rheumatic disease".)
CUTANEOUS MANIFESTATIONS OF COVID-19
Frequency — Studies from around the world have identified a range of potential dermatologic manifestations of COVID-19 [2-8]. Reports of the prevalence of cutaneous manifestations in patients with COVID-19 vary, ranging from less than 1 percent to more than 20 percent of patients [9-17]. Data from two large, population-based studies suggest frequencies of cutaneous manifestations (before the Delta variant) in the range of 10 to 13 percent [13,14].
●In a United Kingdom study during the initial wave of COVID in 2020 that matched self-reported symptoms collected through a COVID symptom application with polymerase chain reaction (PCR) test results, the presence of self-reported body rash or acral rash was associated with a positive SARS-CoV-2 test (odds ratio [OR] 1.67, 95% CI 1.42-1.97) [13].
●Subsequently, a second prospective study from the same group assessed rash, burning rash, erythematopapular rash, urticarial rash, and unusual hair loss during the Delta and Omicron waves of the pandemic [15]. Compared with individuals who tested negative, the prevalence of reported cutaneous manifestations was higher among individuals who tested positive for SARS-CoV-2 during the Delta wave (18 versus 9 percent; OR 2.29, 95% CI 2.22-2.36) and, less markedly, during the Omicron wave (11 versus 10 percent; OR 1.29, 95% CI 1.26-1.33). Similar to other manifestations of COVID-19, the prevalence and characteristics of skin findings and their association with a positive test for SARS-CoV-2 might differ among COVID-19 variants [15].
Clinical presentations — The American Academy of Dermatology's COVID-19 Registry, a collaboration between the American Academy of Dermatology and the International League of Dermatologic Societies, is attempting to collate cases and better define the cutaneous manifestations of COVID-19 [18] (see 'Registries' below). In a 2020 analysis of 171 patients with laboratory-confirmed COVID-19 and cutaneous manifestations from the registry, the most commonly reported cutaneous manifestations were morbilliform rash (22 percent), pernio-like acral lesions (18 percent), urticaria (16 percent), macular erythema (13 percent), vesicular eruption (11 percent), papulosquamous eruption (9.9 percent), and retiform purpura (6.4 percent) [19]. Fever and cough were reported in approximately 60 percent of cases.
●Exanthematous (morbilliform) rash – In several case series, a morbilliform rash predominantly involving the trunk has been reported as the most common cutaneous manifestation of COVID-19 [2,3,10,19-21]. The rash has been noted either at the disease onset or, more frequently, after hospital discharge or recovery [10].
●Pernio (chilblain)-like acral lesions – Pernio (chilblain)-like lesions of acral surfaces ("COVID toes") present as erythematous-violaceous or purpuric macules on fingers, elbows, toes, and the lateral aspect of the feet, with or without accompanying edema and pruritus (picture 1A-B) (see "Pernio (chilblains)"):
•Incidence – Pernio-like lesions have been increasingly reported across the age spectrum during the COVID-19 pandemic, with most cases occurring among adolescents and young adults. In a northern California study, the incidence of chilblains increased during the pandemic (April 2020 to December 2020) compared with the prepandemic period (April 2016 to December 2019), from 5.2 per 100,000 person-years (95% CI 4.8-5.6) to 28.6 per 100,000 person-years (95% CI 26.8-30.4) [22].
•Association with SARS-CoV-2 infection – During the pandemic, pernio-like lesions have been reported in patients with or without confirmed COVID-19 or a history of contact with patients with confirmed COVID-19 and in the absence of documented cold exposure or underlying conditions associated with pernio [2-4,19,22-30]. Among individuals with pernio-like lesions, SARS-CoV-2 PCR positivity rates ranged from 3 to 7 percent during the wild-type wave of the pandemic but decreased during the subsequent waves of SARS-CoV-2 variants. The association between chilblains and COVID-19 remains controversial.
-Among users of the COVID Symptom Study application in the United Kingdom who were tested with SARS-CoV-2 PCR during the wild-type wave of the pandemic, the rate of self-reported acral rash was higher among those who tested positive compared with those who tested negative (3.1 versus 1.8 percent; OR 1.74, 95% CI 1.33-2.28) [13]. During subsequent waves with the SARS-CoV-2 Delta and Omicron variants, the frequency of self-reported acral rash among individuals who tested positive decreased to 1.1 and 0.7 percent, respectively. The association of acral rash with SARS-CoV-2 PCR test positivity was statistically significant for Delta (OR 1.79, 95% CI 1.60-2.01) but not for Omicron (OR 0.96, 95% CI 0.86-1.07) [15].
-In a French series of 311 patients (median age 26 years) with acral manifestations seen between March 2020 and May 2020, 150 patients (49 patients with symptoms suspicious for COVID-19) underwent nasopharyngeal swab reverse transcription (RT)-PCR and/or serology for SARS-CoV-2 [31]. Five of 75 patients were positive for SARS-CoV-2 serology, and 7 of 121 patients were positive for SARS-CoV-2 RT-PCR. Overall, 10 of 170 patients (7 percent) had confirmed COVID-19.
-In the American Academy of Dermatology/International League of Dermatologic Societies registry study, of 318 cases from eight countries, 14 of these cases were PCR positive (4.4 percent) [4].
-In a large, retrospective, cohort study conducted within a health care system in northern California that included 780 patients diagnosed with chilblains between April 2020 and December 2020, of 456 patients who underwent PCR testing for SARS-CoV-2, 17 patients (3.7 percent) were positive [22].
Some authors have noted that a negative PCR would be expected in patients who develop pernio-like lesions 7 to 21 days after initial SARS-CoV-2 infection. Therefore, additional analysis of the antibody profiles of these patients has been evaluated [32].
Positive serology rates of 1 to 17 percent (mainly for SARS-CoV-2 immunoglobulin G [IgG] and immunoglobulin M [IgM]) have been reported in a limited number of patients with pernio-like lesions and negative PCR for SARS-CoV-2 [4,22,33,34]. In most cases, serology was performed only at one point in time.
Of note, in some series of patients, specific immunoglobulin A (IgA) antibodies were detected more frequently than IgG [34,35]:
-In a subset of 97 patients from a series of 780 patients with chilblains reported during the pandemic, single time point IgG positivity rate was 1 percent [22]. IgM and IgA were not tested [22].
-In a French series of 40 consecutive patients with chilblain-like lesions, COVID-19 serology was positive in 12 patients, of whom 7 (17.5 percent) had only IgA and 5 (12.5 percent) had IgG [35].
-In an Italian series of 30 children with pernio-like lesions, of whom 17 were retested at a five- to seven-week interval, the overall positivity rate was 17 percent for IgG and 53 percent for IgA [34].
-In a United States small cohort of 21 patients with chilblains diagnosed during the first wave of the pandemic, only two cases (9 percent) had PCR test-confirmed SARS-CoV-2 infection; positive serology for IgG, IgA, and IgM antibodies against S, receptor binding domain, and nucleocapsid antigens; and evidence of antigen-specific T cell responses to SARS-CoV-2 [36]. Serology and T cell response were negative in the other 19 patients with chilblains.
-In a study of 50 patients with chilblain-like lesions seen during the first wave of the pandemic, PCR testing for SARS-CoV-2 as well as serology for IgG and IgA were negative in all patients [37]. Compared with patients with seasonal chilblains seen before the pandemic, chilblain-like lesions had similar histopathologic and immunohistochemical features, as well as immune transcriptomic signature, with upregulation of type I and II interferon pathways, T helper 1 (Th1) cell polarization, cytotoxicity markers, and natural killer signaling.
•Clinical presentation and course – The majority of patients with pernio-like lesions and confirmed or suspected SARS-CoV-2 infection were asymptomatic or had mild symptoms compatible with COVID-19, with very rare reports of severe COVID-19 in patients with pernio-like lesions [2,4,35,38,39]. In the American Academy of Dermatology/International League of Dermatologic Societies registry study, 55 percent of patients overall were otherwise asymptomatic, and 98 percent of patients in the study were treated in the outpatient setting alone [4]. This finding held true when restricted to laboratory-confirmed cases only, with 78 percent remaining in the outpatient setting.
In patients with confirmed or suspected SARS-CoV-2 infection, pernio lesions started one to four weeks after the onset of COVID-19 symptoms, suggesting a postviral or delayed-onset process. In the American Academy of Dermatology/International League of Dermatologic Societies registry, 80 of 318 cases with pernio-like lesions developed lesions after the onset of other COVID-19 symptoms [4]. In some cases, lesions appeared while patients were still PCR positive for the virus [4,30].
Resolution usually occurred in two to eight weeks. A prolonged course of more than 60 days has been reported in some patients ("long haulers") [40]. Additionally, some patients have developed recurrence of pernio, likely triggered by cold, during the following fall-winter season [41,42].
•Potential pathogenetic mechanisms – Proposed mechanisms for the development of pernio-like lesions during the pandemic include a reaction to the immune response to the virus and pandemic-related lifestyle changes that may increase the risk for pernio. As an example, in a large, cohort study that included 780 patients with pernio seen during the pandemic, 94 percent reported not wearing shoes at home [22].
Examination of biopsied pernio-like lesions demonstrates a primarily inflammatory process, with histopathologic and direct immunofluorescence findings similar to those seen in idiopathic and autoimmune-related pernio [3,26,28,43-46]. (See "Pernio (chilblains)", section on 'Skin biopsy'.)
These inflammatory changes have been hypothesized to be associated with enhanced interferon-alpha responses to the virus and are, at times, associated with an IgA antibody response to the virus [35,40,47].
A French study demonstrated increased in vitro production of interferon-alpha from stimulated peripheral blood T cells in patients with pernio compared with patients with PCR-positive, moderate to severe COVID-19 without pernio, suggesting that a robust, innate immune response may lead to rapid control of the virus in these patients and could, at least in part, explain the relatively mild disease course and low level of antibody production [47].
•Management – There are no treatment guidelines for COVID-19-associated, pernio-like lesions of the feet or hands. However, clinical experience suggests that high-potency topical corticosteroids may be helpful if the lesions are causing discomfort. (See "Pernio (chilblains)", section on 'Management'.)
Although PCR positivity has been found infrequently in patients with pernio during the COVID-19 pandemic and not all cases are necessarily related to COVID-19, it may be prudent that patients presenting with new-onset, pernio-like lesions that have no other clear cause be tested for SARS-CoV-2 PCR within seven days of the onset of pernio lesions [32,48-50]. For patients who have had these lesions for >4 weeks, IgM and IgG antibody testing can be considered, following local guidelines and depending on the quality of available tests, acknowledging that many of these patients may only make transient antibody responses or IgA responses that are not currently being tested in commercial laboratories. A positive serology could rule out other causes of pernio that might need additional work-up. Work-up of other causes of pernio is discussed in greater detail separately [2,4,35]. (See "Pernio (chilblains)", section on 'Diagnosis'.)
●Livedo reticularis-like – Livedo reticularis-like vascular lesions have been reported in a few patients with COVID-19 [19,24,51-55]. In a series of 171 laboratory-confirmed cases, these vascular lesions were noted in 5.3 and 2.3 percent of patients, respectively [19].
●Fixed livedo racemosa/retiform purpura/necrotic vascular lesions – Retiform purpura and necrotic vascular lesions seem to be associated with severe COVID-19 (picture 2A-B) [19,24,56,57]. In a series of 11 patients with retiform purpura and laboratory confirmed COVID-19, all were hospitalized and nine had acute respiratory distress syndrome [19]. In three patients with SARS-CoV-2 infection and severe respiratory failure who had retiform purpura or livedo racemosa, histologic and immunohistochemistry studies of skin biopsies revealed a pattern of complement-mediated microvascular injury in both involved and normally appearing skin [56]. Histopathologic findings of thrombotic vasculopathy and/or laboratory coagulation alterations have also been demonstrated in patients with severe COVID-19 and acral ischemic lesions [43,57]. (See "Approach to the patient with retiform (angulated) purpura" and "Livedoid vasculopathy" and "COVID-19: Hypercoagulability".)
●Urticaria – Acute urticaria with or without concomitant fever has been reported as a presenting sign of COVID-19 infection [2,3,10,19,24,58].
●Vesicular (varicella-like) eruptions – There are several reports describing a vesicular-pustular, varicella-like eruption associated with COVID-19 [2,24,59,60]. In a series of 24 patients, an eruption of small papules, vesicles, and pustules appeared 4 to 30 days after the onset of COVID symptoms and resolved in a median of 10 days [61]. A real-time PCR for SARS-CoV-2 from vesicle content performed in four patients yielded negative results. Seventeen of 24 patients were not taking any medications, ruling out a drug reaction.
●Multisystem inflammatory syndrome in children (MIS-C) – An erythematous, polymorphic rash, erythema and/or firm induration of hands and feet, oral mucositis, and conjunctivitis, along with systemic, laboratory, and imaging findings of atypical, severe Kawasaki disease, were initially described in a cohort of 10 Italian children during the COVID-19 pandemic [62]. Similar cases have been reported in the United Kingdom [63], the United States [64], and other countries. Case definitions for MIS-C have been proposed by the World Health Organization and the United States Centers for Disease Control and Prevention. (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)
Less frequently reported dermatologic manifestations include papulosquamous eruptions [65], erythema multiforme-like lesions [66-68], dengue-like rashes [69,70], petechiae [71], and gangrene [72].
Some infants born to mothers with COVID-19 at birth have had transient rash. In a review of nine small case series from China that included a total of 65 pregnant women who were infected with SARS-CoV-2 during pregnancy and 67 newborns, two newborns presented with a rash [73]. The rash has been described in one infant as a diffuse, maculopapular eruption that resolved in one day with desquamation and in another as a diffuse, red, miliaria-like eruption that disappeared in 10 days without treatment [74].
DERMATOLOGIC CONDITIONS RELATED TO THE COVID-19 PANDEMIC — Skin injury, mechanical/friction dermatitis, and irritant contact dermatitis due to personal protective equipment (PPE) and hand hygiene measures have been reported in the majority of health care workers involved in the direct care of patients with COVID-19 [75].
Personal protective equipment-induced skin injury — Health care workers caring for patients with COVID-19 or patients potentially infected with SARS-CoV-2 may spend long hours wearing PPE. The American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic:
●Mechanical injury/friction dermatitis – PPE-induced skin injury is common, occurring in up to over 90 percent of health care workers [75-78]. Long durations of PPE use (>6 hours per day) increase rates of skin damage [75,76,79]. Masks, goggles, face shields, and gloves apply pressure, create abrasion, and retain moisture and can injure the nasal bridge, cheek, forehead, and hands [75-77]. PPE-induced injuries include desquamation, erythema, maceration, fissuring, papules, and erosions, leading to itching and pain [76].
●Irritant and allergic contact dermatitis – Multiple case series have reported allergic contact dermatitis due to rubber, adhesives, and formaldehyde, as well as irritant contact dermatitis due to pressure and friction, in health care workers wearing N95 or equivalent masks for >6 hours daily [80,81].
●Facial dermatoses ("maskne") – New-onset or exacerbation of facial dermatoses, including acne ("maskne"), rosacea ("mask rosacea"), seborrheic dermatitis, periorificial dermatitis, and folliculitis, likely due to friction and occlusion, have been reported in persons wearing masks for >6 hours per day [80,82,83]. Mask-related Koebner phenomenon (trauma-induced development of lesions clinically similar to the underlying skin disease in previously uninvolved areas) has also been described in patients with a variety of skin disorders, including psoriasis, vitiligo, acne, and rosacea [84].
Prevention of PPE-related injuries has the potential to reduce PPE protocol breaches due to inadvertent adjustment and touching [85]. The use of barrier films or dressings at pressure points before donning PPE may reduce these types of injuries [86-90]. However, the effects of these preventive measures on PPE ability to prevent viral spread are not well characterized, and caution is warranted [85,88].
Hand hygiene-related dermatitis — Hand hygiene is considered a key tool against COVID-19. Hand eczema was already an issue among health care workers and is likely to be an even greater problem with higher rates of hand washing and glove use during the pandemic [91].
The frequency of irritant contact dermatitis of the hands may be reduced by frequent usage of emollients, washing with lukewarm water instead of hot water, and usage of alcohol-based cleansers when hands are not visibly dirty [86,89,92,93]. Overzealous hand hygiene may cause hand eczema in the general population as well [94].
The American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic. (See "Irritant contact dermatitis in adults" and "Chronic hand eczema".)
THERAPEUTIC CONSIDERATIONS DURING THE PANDEMIC — The COVID-19 pandemic has led to necessary adjustments to the therapeutic approach for some dermatologic diseases. Considerations for immunosuppressive therapy are reviewed here. Various professional organizations have also released guidelines for clinical care during the pandemic. (See 'Society guideline links' below and "COVID-19: Care of adult patients with systemic rheumatic disease".)
Use of biologic and other immunosuppressive therapies — Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases, such as psoriasis, atopic dermatitis, and other inflammatory or autoimmune conditions. The risks of these immunomodulatory therapies in relation to COVID-19 remain unclear. Although it is generally accepted that most patients without COVID-19 who are already taking immunosuppressive drugs for dermatologic disease can continue therapy, a more cautious approach is typically taken for patients who have suspected or confirmed COVID-19 and patients who are considering starting a new immunosuppressive therapy. (See 'Patients without COVID-19' below and 'Patients with presumed or confirmed COVID-19' below.)
Recommendations for COVID-19 vaccination in immunocompromised patients are reviewed separately. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals'.)
Assessment of risk — The uncertainty regarding the impact of biologic and other immunosuppressive therapies on SARS-CoV-2 infection risk and COVID-19 severity makes risk assessment challenging [95-97]. Specific challenges for risk assessment include the paucity of data, the various mechanisms of action of immunosuppressive drugs, and the need to consider patient-specific and disease-specific morbidity and comorbidities. Some authors have proposed that the broad immunosuppression induced by small molecule immunosuppressants (eg, cyclosporine, mycophenolate, azathioprine) may be of greater concern than the targeted immunosuppression induced by biologic drugs; however, the relative safety of individual immunosuppressants remains unclear [98].
Consideration of the potential risks of immunosuppressive therapy must also be balanced with consideration of the detrimental effects on skin disease and associated conditions that may result from cessation of effective therapies [99]. Cutaneous disease may flare, and occasional patients may not achieve the same level of response upon the reintroduction of a previously effective biologic therapy [96,97]. Of note, the long half-lives of some biologic agents mean that immunosuppressive effects of concern may still persist for some time following the decision to stop therapy.
Studies evaluating use of immunomodulatory therapies in relation to COVID-19 in patients with dermatologic disease are limited and insufficient for drawing conclusions on risk in this population [100-103]. It is unclear whether data from clinical trials that have assessed risk for upper respiratory infections during biologic therapy for dermatologic disease are applicable to SARS-CoV-2 infection [97,104-106].
In support of the theory that the risks of continuing biologic therapy for skin disease may be low:
●A retrospective study of 5206 patients in northern Italy treated with biologic agents for plaque psoriasis between February 20 and April 1, 2020, found no COVID-19-related deaths and only four COVID-19-related hospitalizations [100].
●A case-control study performed in the Lombardy region of Italy that involved assessment of 1193 patients with psoriasis treated with biologic or small molecule therapy and approximately 10 million controls between February 21 and April 9, 2020, found higher risks for testing positive for COVID-19, being self-quarantined at home due to COVID-19, or being hospitalized due to COVID-19 among patients with psoriasis receiving biologic therapy compared with controls but did not find statistically significant increases in risk for intensive care unit admission or dying in this population [101].
●A cohort study that compared outcomes of COVID-19 in 214 patients treated with tumor necrosis factor (TNF) inhibitors or methotrexate within one year of contracting COVID-19 with over 31,000 patients who did not receive these drugs found no difference in the likelihood of hospitalization or mortality [107].
●An international, registry-based study that included patients with psoriasis and confirmed or suspected COVID-19 infection (n = 374) found that patients receiving biologic therapy were less likely to have a COVID-19-related hospitalization than patients receiving nonbiologic systemic therapy [108].
Although the potential for a beneficial effect of biologic inhibitors TNF-alpha or interleukin (IL) 17 in COVID-19 has been proposed based upon the theory that some immunosuppressive drugs might have inhibitory effects on damaging immune response that is thought to contribute to organ damage in COVID-19, this has not been proven [109-112]. Data on IL-6 pathway inhibitors is reviewed separately. Dexamethasone has been used in the treatment of select patients with severe COVID-19. (See "COVID-19: Clinical features", section on 'Acute course and complications' and "COVID-19: Management in hospitalized adults", section on 'Dexamethasone and other glucocorticoids' and "COVID-19: Management in hospitalized adults", section on 'IL-6 pathway inhibitors (eg, tocilizumab)'.)
Patients without COVID-19 — Decisions on the use of immunosuppressive therapies in patients without signs or symptoms of COVID-19 during the global pandemic should be made on a case-by-case basis and in conjunction with the patient. This may involve review of the patient's comorbidities, severity of the disease originally being treated, limited available data, expert opinion, local recommendations, and patient preference.
Continuation of immunosuppressive therapies — Based upon an absence of evidence that suggests benefit of discontinuing immunosuppressive therapies in patients without COVID-19 and the potential detrimental effects of discontinuing effective therapies, the continuation of biologic and small molecule immunosuppressants for dermatologic disease is generally considered a safe and appropriate option for patients who do not have suspected or documented COVID-19 [113-117].
Initiation of immunosuppressive therapies — Routine avoidance of initiating a new immunosuppressive therapy for dermatologic disease in patients without COVID-19 is not considered necessary. However, given that some uncertainty remains regarding the effects of immunosuppressive therapies on COVID-19, the decision to start a new immunosuppressive drug for dermatologic disease should be taken carefully, involving a case-specific review of the potential risks and benefits of therapy. In particular, for patients perceived to be at increased risk for severe COVID-19, it may be prudent to consider deferring immunosuppressive treatments in favor of other therapies [113]. (See "COVID-19: Clinical features", section on 'Risk factors for severe illness'.)
Some authors have proposed testing for SARS-CoV-2 infection or immunity prior to initiation of immunosuppressive therapies [118]. However, the value of this approach is unclear.
Patients with presumed or confirmed COVID-19 — Active infection is an accepted indication for discontinuation and avoidance of initiation of immunosuppressive therapies, although this remains an area of debate. This approach may be the appropriate default for most patients with confirmed COVID-19. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Management of patients with known or suspected SARS-CoV-2 exposure or infection' and 'Society guideline links' below.)
However, given the uncertainty about the effects of various immunosuppressants on the course of COVID-19, the decision to discontinue treatment in a patient with COVID-19 should be made on a case-by-case basis. Other factors that may influence the decision to cease treatment may include the severity of COVID-19 and the potential negative ramifications of treatment cessation on flaring immunologic activity, including both dermatologic disease and comorbidities. (See "COVID-19: Care of adult patients with systemic rheumatic disease".)
Immunosuppressive therapy can usually be resumed, if needed, following complete recovery from COVID-19. Guidance the National Psoriasis Foundation issued in 2022 supports case-by-case shared decision making for the resumption of systemic antipsoriatic therapies in patients with COVID-19 [114].
Skin cancer — Issues related to the care of patients with cancer during the pandemic are discussed elsewhere. (See "COVID-19: Considerations in patients with cancer".)
CONSIDERATIONS FOR VACCINATION TO PREVENT SARS-COV-2 INFECTION — The development of vaccines to prevent SARS-CoV-2 infection occurred at an unprecedented rate. Vaccines to prevent SARS-CoV-2 infection are reviewed in detail separately. (See "COVID-19: Vaccines".)
Cutaneous adverse events — Examples of reported cutaneous reactions following receipt of COVID-19 vaccines have included injection site reactions; delayed, large, local reactions (also known as "COVID arm"); urticaria; morbilliform eruptions ("maculopapular rash"); pityriasis rosea-like reactions; pernio/chilblains; bullous pemphigoid-like reactions; lichen planus-like reactions; purpuric reactions; herpes zoster; and other findings [119-126]. Cutaneous and other adverse events following COVID-19 vaccines should be reported. (See 'Registries' below.)
A systematic review and meta-analysis of studies that assessed cutaneous adverse events following COVID-19 vaccination provides additional data on the frequency of cutaneous adverse events [127]. The pooled prevalence of cutaneous manifestations was 3.8 percent (95% CI 2.7-5.3 percent, I2 = 99.77) among recipients of messenger ribonucleic acid (mRNA)-based vaccines, inactivated SARS-CoV-2 vaccines, or viral vector-based vaccines. Acute, local injection site reactions were the most frequent cutaneous manifestations, accounting for 72 percent of the 44,582 reported cases of vaccine-related cutaneous manifestations. Subgroup analysis also suggested a higher prevalence of cutaneous adverse events in association with mRNA vaccines compared with other vaccine platforms (prevalence of 6.9 percent, 95% CI 3.8-12.3 percent). Limitations of the meta-analysis included high heterogeneity, uncertain causality between vaccination and reported cutaneous outcomes, and incomplete descriptions of cutaneous outcomes in some reports. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Reactions to specific vaccines'.)
Much higher frequencies of injection site reactions reported in some trials reflect the inclusion of "pain" within the category of injection site reactions (ie, cutaneous manifestations not required) [128].
A grading schema for cutaneous adverse events to COVID-19 vaccines, adapted from the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) drug reaction scale to COVID-19 vaccine reactions, has also been proposed [129].
Features of some of the most reported cutaneous adverse effects include:
●Injection site reactions – Acute injection site reactions are common after vaccination against COVID-19 and other diseases [126,128,130]. Typical symptoms include the development of swelling, erythema, and pain at the vaccination site within one to two days after vaccination. Symptoms usually resolve within several days. Symptomatic treatment can be implemented, when needed. These reactions are not considered contraindications to future vaccination. (See "Allergic reactions to vaccines", section on 'Delayed vaccine reactions'.)
●Delayed local reactions – A delayed local reaction secondary to COVID-19 vaccination (also known as "COVID arm") is an immune-mediated reaction characterized by the development of a well-demarcated, inflamed plaque near the site of mRNA vaccination (picture 3). In contrast to typical injection site reactions, which appear within one to two days after vaccination, the usual time of onset is seven to eight days after vaccination. Delayed local reactions have been most frequently reported following initial vaccination and appear to be more common in females than males [131,132]. Clinically, delayed local reactions may be mistaken for cellulitis. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Late local reactions'.)
Generally, reactions spontaneously resolve within several days, though longer durations have been reported [131]. Antibiotic therapy is not indicated. Delayed local reactions are not considered contraindications to future COVID-19 vaccination. The approach to subsequent vaccination is reviewed separately. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Late local reactions'.)
●Urticaria – Delayed-onset urticaria after vaccination (eg, urticaria developing more than four hours after vaccination, not part of an anaphylactic reaction) has been reported with the original vaccine series and after booster doses [121,133-138]. In addition, a subset of patients may develop chronic, spontaneous urticaria lasting ≥6 weeks [139,140]. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Delayed-onset urticarial reactions' and "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Persistent urticaria'.)
The approach to treatment of urticaria-associated COVID-19 vaccination resembles the approach to urticaria due to other causes. Antihistamines are the mainstay of treatment. Patients with refractory, chronic, spontaneous urticaria that cannot be controlled with antihistamines alone may benefit from other treatments. Improvement with omalizumab after failure of antihistamines is described in a case report [139]. (See "New-onset urticaria", section on 'Treatment' and "Chronic spontaneous urticaria: Standard management and patient education", section on 'Stepwise approach to treatment'.)
The approach to subsequent COVID-19 vaccination in these patients is reviewed separately. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Management'.)
●Morbilliform eruptions – Morbilliform eruptions have been reported after COVID-19 vaccination [126]. The typical clinical findings are widespread, erythematous macules. Associated erythema may be subtle in patients with highly pigmented skin.
Morbilliform eruptions usually spontaneously resolve within one to two weeks [121]. Management consists of supportive therapy for associated symptoms (eg, topical corticosteroids, antihistamines). Morbilliform eruptions are not considered contraindications for future vaccination.
●Vaccine-related eruption of papules and plaques – The term "vaccine-related eruption of papules and plaques" (V-REPP) has been proposed for the group of cutaneous COVID-19 vaccination reactions characterized by the histologic finding of spongiotic dermatitis and clinical findings of papulovesicular (severe V-REPP), pityriasis rosea-like (moderate V-REPP), and papulosquamous skin lesions (mild V-REPP) [124].
V-REPP reactions generally appear at least several days after vaccination and may persist for weeks, months, or longer. In one registry-based study that included 15 patients with findings consistent with V-REPP following receipt of an mRNA vaccine, the median time to development of the eruption was 12 days after vaccination, and many patients continued to have active eruptions at the time of reporting [124]. Several patients who developed pityriasis rosea-like lesions after a first dose of an mRNA vaccine experienced a flare after a second dose of the vaccine.
Development of V-REPP is not considered a contraindication to future vaccine doses. However, given the possibility of persistent eruptions, shared decision making is important.
●Herpes zoster – A 2022 systematic review of the literature identified 160 reports of patients who developed herpes zoster after COVID-19 vaccination [126]. Although vaccine-related immunomodulation was proposed as a potential mechanism, additional study is necessary to confirm a causative relationship.
Soft tissue fillers — Reports of facial swelling following receipt of the mRNA 1273 (Moderna) COVID-19 vaccine in patients with a history of facial soft tissue filler injections suggest a relationship between prior cosmetic soft tissue filler injections and postvaccination swelling, although such reports are rare, and additional data are necessary to confirm an association. A 2022 systematic review identified 16 cases of facial swelling after COVID-19 vaccination in patients with a history of soft tissue fillers and three additional cases following COVID-19 infection [141].
Given the apparent rarity of this adverse event and the expectation for complete resolution of associated facial swelling, decisions to proceed with soft tissue filler injections in close proximity to receipt of the vaccine may involve consideration of patient and provider tolerance for risk for facial swelling as well as consideration of the risks of delaying COVID-19 vaccination. (See "Injectable soft tissue fillers: Overview of clinical use".)
Immunocompromised patients — Limited data suggest vaccination against SARS-CoV-2 is safe in dermatologic patients receiving immunomodulatory therapies [142]. Efficacy of vaccination in this population may vary based upon the type of immunomodulatory therapy and vaccine [142]. Guidance regarding administration of COVID-19 vaccines in immunocompromised patients is provided separately. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals' and "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'COVID-19 vaccination while on immunosuppressive therapy'.)
DELIVERY OF CARE DURING THE PANDEMIC — Local guidelines on the performance of medical care during the pandemic differ and continue to evolve. In many settings, the pandemic led to increased use of telemedicine for dermatologic care (ie, teledermatology). In scenarios in which in-person care remains necessary or appropriate, precautions to limit risk for transmission of infection are indicated. (See 'Telemedicine' below and 'In-person care' below and 'Society guideline links' below.)
Telemedicine — Telemedicine provides an opportunity to provide care while reducing risk for exposure of clinicians, staff, and patients to individuals with COVID-19 [143,144]. Both synchronous (eg, simultaneous, two-way communication between the patient and clinician via telephone or videoconferencing) and asynchronous (eg, store-and-forward transmission of images for later assessment by the clinician) modalities have been utilized for teledermatology care [145]. A structured triage process may be helpful for identifying patients who require in-person, rather than a telemedicine, visit [146,147]. (See "Telemedicine for adults".)
Telemedicine may also be an appropriate option for inpatient dermatologic care in some scenarios. The Society of Dermatology Hospitalists has produced an algorithm to guide triaging of consultations and the performance of safe inpatient dermatologic care [148].
Concerns have been raised over privacy and security of telemedicine [149,150]. The platform selected should be compliant with local privacy regulations. Due to the COVID-19 pandemic, some regulatory bodies have relaxed or waived rules to allow more flexibility in telemedicine [151].
Photography tips for patients seeking telemedicine evaluation for skin conditions are provided in a table (table 1).
In-person care — In-person visits should be performed with appropriate infection control precautions based on current local recommendations and the prevalence of COVID-19 in the local community. (See "COVID-19: General approach to infection prevention in the health care setting".)
Best practices for infection control in the clinical setting are reviewed separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)
REGISTRIES
COVID-19 — Multiple registries have been developed, with the goal of increasing knowledge of the dermatologic manifestations and impact of COVID-19 in patients with dermatologic disease. Examples include:
●General dermatologic manifestations of COVID-19 or patients with COVID-19 and any pre-existing dermatologic condition:
•American Academy of Dermatology/International League of Dermatological Societies COVID-19 Registry
●Psoriasis:
•Psoriasis Registry for Outcomes, Therapy, and Epidemiology of COVID-19 Infection (PsoPROTECT)
•Surveillance Epidemiology of Coronavirus (COVID-19) Under Research Exclusion Registry (SECURE-Psoriasis Registry)
●Atopic dermatitis:
•Surveillance Epidemiology of Coronavirus (COVID-19) Under Research Exclusion Registry (SECURE-AD Registry)
●Alopecia:
•Surveillance Epidemiology of Coronavirus (COVID-19) Under Research Exclusion Registry (SECURE-Alopecia Registry)
●Hidradenitis suppurativa:
•Global Hidradenitis Suppurativa COVID-19 Registry
●Acral changes in the pediatric population:
•COVID Acral Ischemia/Perniosis in Children Registry
Disease registries for rheumatologic diseases are reviewed separately. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Disease registries'.)
COVID-19 vaccine reactions — Reactions to COVID-19 vaccines should be reported. Resources for reporting adverse events include:
●All adverse events:
•Vaccine Adverse Event Reporting System (The United States Centers for Disease Control and Prevention)
●Cutaneous adverse events:
•COVID-19 Dermatology Registry (American Academy of Dermatology and International League of Dermatologic Societies)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics" and "Society guideline links: COVID-19 – Dermatology care".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)" and "Patient education: COVID-19 and children (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Cutaneous manifestations of COVID-19 – Multiple skin manifestations have been described in patients with confirmed or suspected SARS-CoV-2 infection. These include a morbilliform rash; urticaria; pernio-like, acral lesions; livedo-like, vascular lesions; and vesicular, varicella-like eruptions. A severe multisystem inflammatory syndrome with mucocutaneous, systemic, laboratory, and imaging findings of atypical, severe Kawasaki disease has also been reported in children and adolescents with COVID-19. (See 'Cutaneous manifestations of COVID-19' above and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)
●Personal protective equipment and hand hygiene-related dermatoses – Skin injury, mechanical/friction dermatitis, and hand irritant contact dermatitis due to personal protective equipment (PPE) and hand hygiene measures have been reported in the majority of health care workers involved in the care of patients with COVID-19. Use of barrier films or dressings at pressure points of PPE and frequent use of emollients after hand washing may help reduce skin damage and irritation. (See 'Dermatologic conditions related to the COVID-19 pandemic' above.)
●Impact of the pandemic on dermatologic care – The COVID-19 pandemic has contributed to the need to adjust aspects of dermatologic care. Examples include adjustments in the approach to immunosuppressive treatment, phototherapy, skin cancer treatment, and routine clinical care (see 'Therapeutic considerations during the pandemic' above and 'Delivery of care during the pandemic' above):
•Immunosuppressive therapy – The impact of immunosuppressive therapies for dermatologic disease on risk for SARS-CoV-2 infection and risk for complications of COVID-19 is unclear. The decision to continue or start immunosuppressive therapy for dermatologic disease during the pandemic should be made on a case-by-case basis. Examples of important factors to consider include the patient's infection status, the immunosuppressant under consideration, and the impact of treatment cessation on the dermatologic disease and comorbidities (see 'Therapeutic considerations during the pandemic' above):
-Patients without COVID-19 – Given the absence of evidence indicating benefit of discontinuing immunosuppressive therapies in patients without COVID-19, continuation of immunosuppressive therapy for dermatologic disease is considered a safe and appropriate option for this population. The decision to start a new immunosuppressive drug should include careful consideration of potential risks and benefits of therapy. For patients with risk for severe COVID-19, it may be appropriate to defer immunosuppressive treatments in favor of other therapies. (See 'Patients without COVID-19' above.)
-Patients with COVID-19 – Active infection is an accepted indication for discontinuation of immunosuppressive therapies. However, the decision to continue, discontinue, or resume immunosuppressive treatment in patients with presumed or confirmed COVID-19 should be made on a case-by-case basis. (See 'Patients with presumed or confirmed COVID-19' above.)
•Delivery of care – The COVID-19 pandemic has contributed to increased use of telemedicine for routine clinical care. When in-person visits are performed, appropriate infection control precautions should be implemented. (See 'Delivery of care during the pandemic' above and "COVID-19: General approach to infection prevention in the health care setting".)
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