The current coronavirus disease-19 (COVID-19) pandemic has increasingly shown dermatological manifestations in the last few months as extrapulmonary signs associated with COVID-19.

The polymorphic nature of COVID-19-associated cutaneous manifestations led a group of researchers to propose a classification, which distinguishes the following six main clinical patterns: (i) urticarial rash, (ii) confluent erythematous/maculopapular/morbilliform rash, (iii) papulovesicular exanthem, (iv) chilblain-like acral pattern, (v) livedo reticularis/racemosa-like pattern, (vi) purpuric “vasculitic” pattern. 

1. i) Urticarial rash- it presents itself as an itching rash, predominantly involving the trunk and limbs which may be sometimes associated with angioedema. It is most frequently reported in the intermediate severity COVID-19 infection.

Histopathological findings include vacuolar interface dermatitis associated with superficial perivascular lymphocytic infiltrate.

The treatment options include Low-dose systemic corticosteroids combined with nonsedating antihistamines.

1. ii) Confluent erythematous/maculopapular/morbilliform rash- It presents as a generalized, symmetrical lesion initiating from the trunk with centrifugal progression. Additionally, purpuric lesions may coexist from the onset or may even develop during the course of the skin eruption. It is most frequently reported in the intermediate severity COVID-19 infection.

Histopathological findings include superficial perivascular lymphocytic and/or neutrophilic infiltrate.

The treatment options include the use of topical corticosteroids for mid cases and the use of systemic corticosteroids for severe cases.

 (iii) Papulovesicular exanthema- it may show- a) widespread polymorphic pattern consisting of small papules, vesicles and pustules of different sizes, b) localized pattern consisting of papulovesicular lesions, usually involving the mid-chest/upper abdominal region or the back. It is most frequently reported in the intermediate severity COVID-19 infection.

Histopathological findings include prominent acantholysis and dyskeratosis associated with unilocular intraepidermal vesicles in a suprabasal location.

The treatment option utilizes the wait and watch strategy.

(iv)  Chilblain-like acral pattern- it presents itself as erythematous-violaceous patches or plaques predominantly involving the feet or, to a lesser extent, hands. Pain/burning sensation and pruritis were found to be the most common symptoms. It is most frequently reported in the asymptomatic status COVID-19 infection.

Histopathological findings include perivascular and periadnexal dermal lymphocytic infiltrate.

The treatment option utilizes the wait and watch strategy.

(v) Livedo reticularis/racemosa-like pattern- Livedo reticularis like lesions presents as mild, transient, symmetrical, lace-like, dusky patches forming complete rings surrounding a pale center. Livedo racemosa like lesions presents themselves as large, irregular and asymmetrical violaceous annular lesions frequently described in patients with severe coagulopathy.

Livedo reticularis like lesions are most frequently reported in the intermediate severity COVID-19 infection, while Livedo racemosa like lesions are reported in the high severity COVID-19 infection.

Histopathological findings include pauci-inflammatory microthrombotic vasculopathy.

The treatment option utilizes the wait and watch strategy.

(vi)  Purpuric “vasculitic” pattern- it mainly presents as the purpuric lesions which may be generalized, arranged in an acral distribution or can be localized in the intertriginous regions. Purpuric elements may evolve into hemorrhagic blisters, possibly leading to necrotic-ulcerative lesions. It is most frequently reported in the high severity COVID-19 infection.

Histopathological findings include leukocytoclastic vasculitis, severe perivascular neutrophilic and lymphocytic infiltrate, presence of fibrin and endothelial swelling.

The treatment options include the usage of topical corticosteroids for mild cases while the use of systemic corticosteroids for severe cases.

Source: Genovese G, Moltrasio C, Berti E, Marzano A, V: Skin Manifestations Associated with COVID-19: Current Knowledge and Future Perspectives. Dermatology 2021;237:1-12. doi: 10.1159/000512932