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Forum for Nord Derm Ven 2020, Vol. 25, No. 1 1
ReviewReview
Coronavirus COVID-19 and Relevance
for Dermatologists – Are We Ready for
the Battle?
Carsten sauer Mikkelsen1,2, kristian Bakk e arvesen2,
luit Penninga3, and Peter Bjerring2
1Specialist in Dermato-venereology, Private Practice in Derma-
to-venereology, Brønderslev, Denmark, 2Specialist in Dermato-venereology, Research lab. Department of Dermato-venereology,
Aalborg University Hospital, Denmark, and 3Specialist in Surgery, Ilulissat Hospital, Avannaa Region, Ilulissat, Greenland.
On December 31, 2019, the first registered case of “atypical ARDS/interstitial pneumonia” came from the
Chinese city of Wuhan, Hubei. On February 11, 2020 the WHO officially announced the new name of the
patho logy associated with the coronavirus: COVID-19 (Coronavirus Disease 2019) (1). It is a new strain of RNA
virus that has not previously been identified in humans.
Cutaneous manifestation in patient s wi th Corona
CoViD-19
Data in the literature so far about skin manifestations in
COVID-19 are very limited.
A group of dermatologists from Lecco in Italy collected data
from 88 patients with COVID-19. Eighteen patients (20.4%)
developed cutaneous manifestations. Eight patients devel-
oped cutaneous involvement at the onset, 10 patients only
after hospitalization. The cutaneous manifestations seen
were: erythematous rash (14 patients), widespread urticaria
(3 patients), and chicken-pox like vesicles (1 patient). The
skin on the trunk was the main involved region. Itching was
insignificant or absent and usually lesions
healed in few days. Apparently, there was
no correlation between skin symptoms
and disease severity. It was concluded that
skin manifestations related to COVID-19
infection are similar to those occurring
during common viral infections (1).
A case report from Thailand presented a
patient with a skin rash with petechiae.
Because dengue is very common in Thai-
land and the patient also had low platelet
count, a clinical diagnosis of dengue was made by the first
physician in-charge. In this case, the patient further presented
respiratory problems and was referred to the tertiary medical
centre. Other common virus infections that might cause fever,
rash and respiratory problem were ruled out by laboratory
investigation and the final diagnosis of COVID-19 infection
was confirmed by RT-PCR (6). The group concluded it is a pos-
sibility that a COVID-19 patient might initially present with
a skin rash which can be misdiagnosed as another common
disease. Additionally, some of these COVID-19 patients are
afebrile initially (3).
More case reports from China present COVID-19 patients with
urticaria as a clinical cutaneous manifestation (7).
Another study from Wuhan registered the clinical character-
istics of 140 community-infected patients with COVID-19. It
was found that the median age of all patients were 57 years
old with almost 1:1 male:female ratio. Fever (91.7 %), cough
(75.0%) and fatigue (75%), were the most common symptoms
in COVID-19 patients. More than 1/3 of the patients had chest
tightness or dyspnoea and gastrointestinal symptoms (nausea,
diarrhoea, and anorexia). CT scans or
X-ray showed bilateral ground-glass and
patchy opacity in 89.6% of the patients.
No asthmatic patients were identified in
this report, and only a few patients had
self-reported drug hypersensitivity and
urticaria. Other allergies such as allergic
rhinitis, atopic dermatitis, and food aller-
gy were not reported (8).
A retrospective study found 7 critical
COVID-19 patients with acro-ischaemia
in a single centre in Wuhan. All patients had acro-ischaemia
presentations including finger/toe cyanosis, skin bullae and
dry gangrene. D-dimer, fibrinogen and fibrinogen degra-
dation product (FDP) were significantly elevated in most
patients. Prothrombin time (PT) were prolonged in 4 pa-
tients. D-dimer and FDP levels increased progressively when
COVID-19 exacerbated, and 4 patients were diagnosed with
definite disseminated intravascular coagulation (DIC). Six
Foto: Alissa Eckert, MS; Dan Higgins, MAMS
Carsten Sauer Mikkelsen et al. – Coronavirus COVID-19 and relevance for dermatologists – are we ready for the battle?
Forum for Nord Derm Ven 2020, Vol. 25, No. 1
2 Letter to the editor
patients received low molecular weight heparin (LMWH)
treatment, after which their D-dimer and FDP decreased, but
there was no significant improvement in clinical symptoms.
Five patients died finally and the median time from acro-
ischaemia to death was 12 days. It was concluded that hyper-
coagulation status in critical COVID-19 patients should be
monitored closely, and that anticoagulation therapy should
be considered in selected patients (9).
Conclusion
The data from studies concerning cutaneous manifestations in
patients with COVID-19 varies a lot. Nevertheless, dermatolo-
gists should recognize the possibility that COVID-19 patients
might present with only a skin rash initially, and should think
of the possibility of the patient having Corona COVID-19 in
order to prevent further transmission.
Cutaneous manifestation in hea lthC ar e workers
fighting Corona CoViD-19
In a study from China the skin damage among healthcare
workers (HCW) managing corona virus COVID-19 was reg-
istered. The general prevalence of skin damages caused by
enhanced infection-prevention measures was 97.0% among
first-line HCW. The affected sites included nasal bridge, hands,
cheek and forehead, and nasal bridge was the most common-
ly affected (83.1%). Among a series of symptoms and signs,
dryness/tightness and desquamation were the most common
symptom (70.3%) and sign (61.6%). The HCW who wore some
medical devices longer than 6 h had higher risks of skin dam-
ages than those who did less time. The more frequent (>10
times/day) hand hygiene and longer time of gloves wearing
could increase the risk of skin damages of the hands.
In conclusion, the study demonstrated that the prevalence
of skin damages of first-line HCW was very high. Moreover,
longer exposure time was a significant risk factor which
highlights that the working time of first-line staff should be
arranged reasonably. Besides, prophylactic dressings could be
considered to alleviate device-related pressure injuries (10).
The above information has been highlighted in a letter from
AAD and suggestions for prevention are given for healthcare
workers (HCW). HCWs fighting COVID-19 are prone to dam-
age of both skin and mucosa barriers. In order to minimize
skin and mucosa barrier breakdown, HCWs should adhere
to standards on wearing protective equipment and avoid
over-protection. At the same time, measures of skin care are
recommended during work. AAD also provides professional
advice on prevention and management of mild skin disorders.
Nevertheless, timely referral to dermatologists is necessary if
dermatoses are sustained or worsened gradually (11,12).
patients with Corona CoViD-19 skin Diseases anD
immunosuppressiVe treatment
The British Association of Dermatologists (BAD) has addressed
potential issues regarding COVID-19 infection of patients
who are taking medicines that affect the immune system
such as biologic therapies and/or immunosuppressants (13).
BAD inform patients taking a medication that targets their
immune system that COVID-19 infection may pose a higher
risk and therefore specific measures are advised. There are
two categories of measures: shielding and very careful social
distancing. Shielding is a measure to protect people who are
at very high risk of severe illness if contracting (COVID-19)
infection by minimising all face to face interaction between
those who are extremely vulnerable and others. Shielding is a
step up from very careful social distancing. People advised not
leave their home for 12 weeks (current estimate until late June
2020). Asking people to stay at home and avoid contact is an
intensified form of social distancing. For people taking drugs
that target the immune system, very careful social distancing
is advised by BAD.
Which category that applies to an actual patient depends on
the medicine(s), age and what other medical problems the
patient may have. The patient will be advised by the doctors
prescribing their immune modulating drugs whether they
are considered an ‘extremely vulnerable’ person needing to
shield. BAD do not advise patients to stop their medicine with-
out prior discussion with their dermatologist since stopping
treatment could worsen their skin condition resulting in need
for hospital treatment. Self-isolation applies if the patients
have symptoms of COVID-19 infection or if the patient lives
with someone who has symptoms. In this case they may NOT
leave the house for 7–14 days. Many out-patient services are
arranging for patients to be reviewed by telephone or online.
The hospital departments contact patients to confirm these
arrangements. Review and frequency of routine blood tests
may become less often during this time but hospitals have
made arrangements for easy access to bloods tests in their
departments on a daily basis.
Patients on biologics will continue to receive their biologics
via homecare delivery companies. BAD are not aware of
any current stock- or delivery issues. Each hospital and GP
practice will make its own arrangements for arranging repeat
prescriptions.
BAD advice that dermatologists should only be starting or
continuing patients on isotretinoin where the risks are out-
weighed by the benefits. This needs to be considered carefully
in light of the need to reduce face-to-face consultations in the
current pandemic, and the uncertainty of reliable follow-up/
Carsten Sauer Mikkelsen et al. – Coronavirus COVID-19 and relevance for dermatologists – are we ready for the battle?
Forum for Nord Derm Ven 2020, Vol. 25, No. 1 review 3
monitoring over the coming months. Monitoring of side
effects and blood monitoring, will need to be carried out as
usual with remote consultations.
Skin cancer services should be attenuated to ensure that
the following guidance is implemented according to BAD:
Consider cancelling all elective surgeries. Consider deferring
all surgical excisions of BCC, including Mohs micrographic
surgery, for 3–6 months, with exceptions for highly-symp-
tomatic lesions. Highly symptomatic lesions and those with
potential for significant rapid growth could be considered for
surgery. Consider deferring surgical excisions of squamous cell
carcinomas (SCC), such as SCC in situ and small, well differen-
tiated SCCs. Prioritise the following lesions: Rapidly-enlarging
tumours, poorly-differentiated tumours, perineural tumours,
ulcerated and symptomatic lesions; lesions in patients with
significant risk factors (while balancing the risk of COVID-19
complications for these high-risk patients). Consider deferring
treatment of melanoma in situ for 2–3 months.
referenCes:
1. Recalcati SJ. Skin manifestations of coronavirus cutaneous man-
ifestations in COVID-19: a first perspective. Letter to Editor. Eur
Acad Dermatol Venereol 2020 Mar 26. doi: 10.1111/jdv.16387.
2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemi-
ological and clinical characteristics of 99 cases of 2019 novel
coronavirus pneumonia in Wuhan, China: a descriptive study.
Lancet 2020; 395: 507–513.
3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features
of patients infected with 2019 novel coronavirus in Wuhan, China.
Lancet 2020; 395: 497–506.
4. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical character-
istics of 138 hospitalized patients with 2019 novel coronavirus-in-
fected pneumonia in Wuhan, China. JAMA 2020; 323: 1061–1069.
5. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus
disease 2019 in China. N Engl J Med 2020 Feb 28. doi 10.1056/
NEJMoa2002032. Epub ahead of print.
6. Joob, B, Wiwanitkit, V. COVID-19 can present with a rash and
be mistaken for Dengue. J Am Acad Dermatol 2020, Mar 22, doi:
https://doi.org/10.1016/ j.jaad.2020.03.036.
7. Shubiao L, Linsong L, Zhiqiao Z, Xiao L, Jiang Z, Chen J, et al.
Alert for non-respiratory symptoms of Coronavirus Disease 2019
(COVID-19) patients in epidemic period: A case report of familial
cluster with three asymptomatic COVID-19 patients. J Med Virol
2020, March 19. doi: 10.1002/jmv.25776. [Epub ahead of print]
8. Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Clin-
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Wuhan, China. Allergy EAACI March 2020, doi: 10.1111/all.14238.
9. Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J, et al. Clinical and
coagulation characteristics of 7 patients with critical COVID-19
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2020 Mar 28;41(0).
10. Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al. Skin damage among
healthcare workers managing coronavirus disease-2019. J Am Acad
Dermatol 2020 Mar 18: S0190-9622(20)30392-3. doi: 10.1016/j.
jaad.2020.03.014. [Epub ahead of print].
11. Elston DM. Letter from the Editor: Occupational skin disease
among healthcare workers during the Coronavirus (COVID-19) ep-
idemic. J Am Acad Dermatol 2020 Mar. i: S0190-9622(20)30390-X.
doi: 10.1016/j.jaad.2020.03.012. [Epub ahead of print]
12. Yan Y, Chen H, Chen L, Cheng B, Diao P, Dong L, et al. Consensus
of Chinese experts on protection of skin and mucous membrane
barrier for health-care workers fighting against coronavirus disease
2019. Dermatol Ther 2020 Mar 13:e13310. doi: 10.1111/dth.13310.
[Epub ahead of print]
13. British Association of Dermatology. Advice for Dermatology
HCPs during Covid-19 Pandemic. Homepage BJD https://www.
bad.org.uk/.
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Article
Full-text available
Health professions preventing and controlling Coronavirus Disease 2019 are prone to skin and mucous membrane injury, which may cause acute and chronic dermatitis, secondary infection and aggravation of underlying skin diseases. This is a consensus of Chinese experts on protective measures and advice on hand‐cleaning‐ and medical‐glove‐related hand protection, mask‐ and goggles‐related face protection, UV‐related protection, eye protection, nasal and oral mucosa protection, outer ear and hair protection. It is necessary to strictly follow standards of wearing protective equipment and specification of sterilizing and cleaning. Insufficient and excessive protection will have adverse effects on the skin and mucous membrane barrier. At the same time, using moisturizing products is highly recommended to achieve better protection. This article is protected by copyright. All rights reserved.
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