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Forum for Nord Derm Ven 2020, Vol. 25, No. 1 1
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
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).
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
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.
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ResearchGate has not been able to resolve any citations for this publication.
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.
Full-text available
Background: Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods: We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results: The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions: During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.).
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Background: Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus -2 (SARS-CoV-2) infection has been widely spread. We aim to investigate the clinical characteristic and allergy status of patients infected by SARS-CoV-2. Methods: Electronical medical records including demographics, clinical manifestation, comorbidities, laboratory data and radiological materials of 140 hospitalized COVID-19 patients, with confirmed result of SARS-CoV-2 viral infection were extracted and analysed. Results: An approximately 1:1 ratio of male (50.7%) and female COVID-19 patients was found, with an overall median age of 57.0 years. All patients were community acquired cases. Fever (91.7%), cough (75.0%), fatigue (75.0%) and gastrointestinal symptoms (39.6%) were the most common clinical manifestations, whereas hypertension (30.0%) and diabetes mellitus (12.1%) were the most common comorbidities. Drug hypersensitivity (11.4%) and urticaria (1.4%) were self-reported by several patients. Asthma or other allergic diseases was not reported by any of the patients. Chronic obstructive pulmonary disease (COPD, 1.4%) and current smokers (1.4%) were rare. Bilateral ground glass or patchy opacity (89.6%) were the most common signs of radiological finding. Lymphopenia (75.4%) and eosinopenia (52.9%) were observed in most patients. Blood eosinophil counts correlate positively with lymphocyte counts in severe (r=0.486, p<0.001) and non-severe (r=0.469, p<0.001) patients after hospital admission. Significantly higher levels of D-dimer, C-reactive protein and procalcitonin were associated with severe patients compared to non-severe patients (all p<0.001). Conclusion: Detailed clinical investigation of 140 hospitalized COVID-19 cases suggest eosinopenia together with lymphopenia may be a potential indicator for diagnosis. Allergic diseases, asthma and COPD are not risk factors for SARS-CoV-2 infection. Elder age, high number of comorbidities and more prominent laboratory abnormalities were associated with severe patients.
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Importance In December 2019, novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited. Objective To describe the epidemiological and clinical characteristics of NCIP. Design, Setting, and Participants Retrospective, single-center case series of the 138 consecutive hospitalized patients with confirmed NCIP at Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 28, 2020; final date of follow-up was February 3, 2020. Exposures Documented NCIP. Main Outcomes and Measures Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. Outcomes of critically ill patients and noncritically ill patients were compared. Presumed hospital-related transmission was suspected if a cluster of health professionals or hospitalized patients in the same wards became infected and a possible source of infection could be tracked. Results Of 138 hospitalized patients with NCIP, the median age was 56 years (interquartile range, 42-68; range, 22-92 years) and 75 (54.3%) were men. Hospital-associated transmission was suspected as the presumed mechanism of infection for affected health professionals (40 [29%]) and hospitalized patients (17 [12.3%]). Common symptoms included fever (136 [98.6%]), fatigue (96 [69.6%]), and dry cough (82 [59.4%]). Lymphopenia (lymphocyte count, 0.8 × 10⁹/L [interquartile range {IQR}, 0.6-1.1]) occurred in 97 patients (70.3%), prolonged prothrombin time (13.0 seconds [IQR, 12.3-13.7]) in 80 patients (58%), and elevated lactate dehydrogenase (261 U/L [IQR, 182-403]) in 55 patients (39.9%). Chest computed tomographic scans showed bilateral patchy shadows or ground glass opacity in the lungs of all patients. Most patients received antiviral therapy (oseltamivir, 124 [89.9%]), and many received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]) and glucocorticoid therapy (62 [44.9%]). Thirty-six patients (26.1%) were transferred to the intensive care unit (ICU) because of complications, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]), and shock (11 [30.6%]). The median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days. Patients treated in the ICU (n = 36), compared with patients not treated in the ICU (n = 102), were older (median age, 66 years vs 51 years), were more likely to have underlying comorbidities (26 [72.2%] vs 38 [37.3%]), and were more likely to have dyspnea (23 [63.9%] vs 20 [19.6%]), and anorexia (24 [66.7%] vs 31 [30.4%]). Of the 36 cases in the ICU, 4 (11.1%) received high-flow oxygen therapy, 15 (41.7%) received noninvasive ventilation, and 17 (47.2%) received invasive ventilation (4 were switched to extracorporeal membrane oxygenation). As of February 3, 47 patients (34.1%) were discharged and 6 died (overall mortality, 4.3%), but the remaining patients are still hospitalized. Among those discharged alive (n = 47), the median hospital stay was 10 days (IQR, 7.0-14.0). Conclusions and Relevance In this single-center case series of 138 hospitalized patients with confirmed NCIP in Wuhan, China, presumed hospital-related transmission of 2019-nCoV was suspected in 41% of patients, 26% of patients received ICU care, and mortality was 4.3%.
Objective: To investigate the clinical and coagulation characteristics of the critical Coronavirus disease 2019 (COVID-19) patients with acro-ischemia in the intensive care unit (ICU). Methods: The retrospective study included 7 critical COVID-19 patients with acro-ischemia in a single center in Wuhan, from Feb 4 to Feb 15, 2020. The clinical and laboratory data before and during the ICU stay were analyzed. Results: The median age of 7 patients was 59 years and 4 of them were men. 3 of them were associated with underlying comorbidities. Fever, cough, dyspnea and diarrhea were common clinical symptoms. All patients had acro-ischemia presentations including finger/toe cyanosis, skin bulla and dry gangrene. D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients. Prothrombin time (PT) were prolonged in 4 patients. D-dimer and FDP levels increased progressively when COVID-2019 exacerbated, and 4 patients were diagnosed with definite disseminated intravascular coagulation (DIC). 6 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. 5 patients died finally and the median time from acro-ischemia to death was 12 days. Conclusions: The existence of hypercoagulation status in critical COVID-2019 patients should be monitored closely, and anticoagulation therapy can be considered in selected patients. More clinical data is needed to investigate the role of anticoagulation in COVID-2019 treatment.
In December 2019 unexplained pneumonia cases were initially reported in Wuhan, China. The pathogen, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was isolated from lower respiratory tract samples of infected patients and the resultant disease was termed as COVID‐19 (Coronavirus Disease 2019)¹. By Feb 15, COVID‐19 has rapidly spread throughout China and across the world, until a pandemic condition was announced by March 11².
At present, Coronavirus Disease 2019 (COVID‐19) is rampaging around the world. However, asymptomatic carriers intensified the difficulty of prevention and management. Here we reported the screening, clinical feathers, and treatment process of a family cluster involving three COVID‐19 patients. The discovery of the first asymptomatic carrier in this family cluster depends on the repeated and comprehensive epidemiological investigation by disease control experts. In addition, the combination of multiple detection methods can help clinicians find asymptomatic carriers as early as possible. In conclusion, the prevention and control experience of this family cluster showed that comprehensive rigorous epidemiological investigation and combination of multiple detection methods were of great value for the detection of hidden asymptomatic carriers. This article is protected by copyright. All rights reserved.