Cutaneous manifestations of COVID-19: Report of three cases and a review of literature

<p><u>Case 1 :</u> A 71-year-old Caucasian female without comorbidities, long-term treatment or a history of adverse drug reactions. Admission to the emergency service of Milan for fever, productive cough and dyspnea worsening for 10 days (husband diagnosed COVID +). Normal white blood cell and platelet counts, normal kidney and liver function, CRP 49.4 mg / L. Bilateral interstitial lung disease on chest radiography. RT PCR Positive for SARS-CoV-2 by nasopharyngeal swab testing. Transfer to the infectious diseases department, treatment by combination of LOPINAVIR / RITONAVIR and HYDROXYCHLOROQUINE and probabilistic antibiotic therapy with CEFTRIAXONE. Administration during hospitalization of: PARACETAMOL, RABEPRAZOLE, METOCLOPRAMIDE, DIHYDROCODEINE, LACTULOSE and LMWH (by subcutaneous route). Rapid clinical improvement [lapse not specified], discontinuation of antivirals and antibiotics [total duration of treatment not specified]. <strong> In the following days </strong> [unspecified] <strong> a pruritic maculopapular rash appears on the trunk, similar to Grover's disease </strong> (transient acantholytic dermatosis)<strong>.</strong></p>

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<p><u>Case 2 :</u> A 77-year-old Caucasian woman admitted to the Milan hospital for: cervical lymphadenopathy, fever, cough and <strong> diffuse maculopapular (morbilliform) exanthem on the trunk. One day after her hospitalization, development of a "hemorrhagic rash" on the legs. </strong> RT PCR Positive for SARS-CoV-2 by nasopharyngeal swab testing. Chest X ray negative for pneumonia. Treatment by combination of LOPINAVIR / RITONAVIR, HYDROXYCHLOROQUINE and LMWH (by subcutaneous route). Progressive regression of lesions was observed [time not specified]. </p>

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<p><u>Case 3 :</u> A 72-year-old Caucasian woman without comorbidity, admitted to the emergency room of the Milan hospital for: headache, arthralgia, myalgia and fever. 4 days later, <strong>pruritic papulo-vesicular eruption in the sub-mammary folds, trunk and hips. </strong> Laboratory examination revealed slight increase in white blood cell count, CRP and SV [values not specified]. RT PCR positive for SARS-CoV-2 by nasopharyngeal swab testing. Chest X ray negative for pneumonia. <strong> Complete remission </strong> of general signs and <strong> skin signs 10 days after clinical onset. </strong> </p>

<p><u>Literature review </u>: 18 articles, including 6 case series and 12 case reports. Total of 72 patients. Average age 53.6 years (range 15 days - 84 years). 97.2% of confirmed cases. </p>

<p> - most described dermatological manifestations: <strong> diffuse macular or maculo-papular exanthem (morbilliform) </strong> in <strong> 36.1%</strong> of patients, then <strong>pruritic papulo-vesicular rash </strong>in<strong> 34.7% </strong> <strong> of </strong> patients, <strong> painful acral red purple papules, with or without vesicles </strong> in <strong> 15, 3% </strong> of patients and hives in 9.7% of patients; 2 patients (2.8%) with livedo reticularis lesions, 1 patient (1.4%) with petechiae. </p>

<p>- <strong> preferential location: trunk </strong> in <strong> 69.4% </strong> of patients; note hand and foot injuries in 19.4% of patients </p>

<p>- of the 50 patients who developed skin manifestations after respiratory symptoms, 74% developed lesions within 7 days. </p>

<p>- of the 50 cases with reported dermatological healing: 100% healing of cutaneous lesions, 48% within 7 days. </p>

<p>- of the 23 patients with report on possible association between COVID-19 and skin lesion severity: 91.3% unlikely to be or not correlated. </p>