Photo Credit: US Center for Disease Control and Prevention (CDC)
Erythematous rash, patient's shoulder, 1964, CDC

It’s already become clear that COVID-19, the disease caused by SARS-CoV-2, the new coronavirus, is a much more complex virus than anything that has been seen before. Medical experts, epidemiologists and public health officials are still working around the clock to learn about the illness and how it affects the human body — and how it affects animals as well.

One of the challenges is the changing profile of the symptoms of the virus; more signs keep appearing and modulating almost every week, including those which are cutaneous.


Researchers who carried out the largest published study to date conducted their research in Spain, with 375 cases, identifying five clinical patterns. Theypublished their findings in the British Journal of Dermatology on April 29, 2020. Graeme M. Lipper, MD, writes a commentary on the Medscape website, noting that because of the scarcity and low sensitivity of diagnostic tests available, the investigators accepted patients with confirmed disease as well as those with a clinical diagnosis of COVID in the study.

Just under half (41%) of the patients with pseudo-chilblains in the study had confirmed infection with positive viral cultures and/or serology, he noted.

The researchers found that lesions “may be classified as acral areas of erythema with vesicles or pustules (Pseudo‐chilblain) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%).

“Vesicular eruptions appear early in the course of the disease (15% before other symptoms),” the researchers wrote. The pseudo‐chilblain pattern frequently appears late in the evolution of the COVID‐19 disease (59% after other symptoms), while the rest tend to appear with other symptoms of COVID‐19. Severity of COVID‐19 shows a gradient from less severe disease in acral lesions to most severe in the latter groups. Results are similar for confirmed and suspected cases, both in terms of clinical and epidemiological findings. Alternative diagnoses are discussed but seem unlikely for the most specific patterns (pseudo‐chilblain and vesicular).”

Last month, doctors from Kuwait described “COVID Toes” – COVID-19 infected patients who developed reddish-purple lesions on their fingers or toes that resembled chilblains (hence, the term “pseudo-chilblains”) – which can appear as a symptom even if an individual who tests positive for the virus is otherwise completely asymptomatic.

Two women who had traveled to the UK developed the symptom, and who both subsequently tested positive for COVID-19, were seen by Dr. Anwar Alramthan, a dermatologist at the Quttainah Medical Center in Kuwait. Alramthan is the coauthor of a report that was published on the new symptom in Clinical and Experimental Dermatology.

Dr. Alramthan was not convinced the symptom was caused by the virus but “related with the globally imposed strict stay-at-home rules.” In his opinion, “this acral manifestations should be better classified as pernio… cold temperatures could also have contributed to the appearing of this outbreak of pernio.”

Kids’ Inflammatory Syndrome May Have Rash
Doctors have also been wrestling with a gut-wrenching, deadly COVID-related pediatric inflammatory syndrome that is killing children and which mimics toxic shock syndrome and Kawasaki disease; the latter includes a blotchy red (erythematous) rash as one of its symptoms.

Prior to the COVID Toes and the deadly pediatric inflammatory syndrome, doctors were describing the appearance in some cases of a simple, urticaria rash at the onset of the virus.

A report from dermatologists who worked with 88 COVID-19-positive patients at the Alessandro Manzoni Hospital in Lecco, Lombardy, Italy said that from the collected data, 20 percent of those affected developed skin symptoms. Slightly less than half developed a rash at the onset of the disease, and slightly more than half developed the rash after they were hospitalized.

According to the report, the most common rash was a patchy red (erythematous) rash, but a few of the patients developed simple urticaria, or hives. One patient developed blisters (vesicles) similar to varicella, or chicken pox.

“Of the 88 COVID-19 patients, 20.5% developed skin manifestations,” the researchers said.

COVID Pox, Common Rash, Easy to Misdiagnose
Eight of the 18 patients with skin symptoms (44%) had skin eruptions at symptom onset, and the rest after hospitalization. “Fourteen (78%) had red rashes, three had widespread urticaria, and one had chickenpox-like vesicles. The most commonly affected area was the trunk. Itching was mild or absent, and lesions usually healed up in a few days. Most importantly, skin manifestations did not correlate with disease severity.

These skin manifestations were “similar to cutaneous involvement occurring during common viral infections,” said the author of the report, Sebastiano Recalcati, MD, a dermatologist at Alessandro Manzoni Hospital, who published his report on March 26, 2020.

Doctors in Thailand described another COVID-19 patient who developed petechiae, or broken blood vessels – which is similar to that seen in dengue.

There is a possibility that a COVID-19 patient might initially present with a skin rash that can be misdiagnosed as another common disease, researchers said.

“The practitioner should recognize the possibility that the patient might have only a skin rash” at first, said the lead author of that report, Beuy Joob, PhD, of the Sanitation1 Medical Academic Center, Bangkok, and a coauthor.

In the United States dermatologists are reaching similar conclusions.

Mottling Could Indicate Serious Situation
Sarah Young, MD, a medical dermatologist at the Cleveland Clinic, has noted that the appearance of dermatological symptoms in COVID-19 is not yet widely known outside the dermatology community.

Young spoke about reports of COVID-19 patients developing livedo reticularis, or mottling, which she said could indicate occlusion (blockage) of blood vessels near the skin.

Dr. Randy Jacobs, an assistant clinical professor of dermatology at the University of California, Riverside with a private practice in southern California, was quoted by MDedge Dermatology on the issue of skin symptoms and COVID-19.

Jacobs said clearly that disease can and does present with cutaneous symptoms in some cases.

“COVID-19 can feature signs of small blood vessel occlusion. These can be petechiae or tiny bruises, and transient livedoid eruptions,” he said in an interview. Blockages in small blood vessels, depending on where they are, can lead to very big problems; they can be deadly if they are in organs like the kidneys, the lungs, the brain or the heart. Anywhere, in fact.

Here’s the Bottom Line
The bottom line is this: COVID-19 is still producing unpleasant surprises for doctors around the world. Our health care professionals on the front lines need our support, our prayers and our patience more than ever.

Israel’s Health Ministry directives and for that matter, any government directives anywhere that are intended to prevent pandemic illness and deaths of thousands more of the population, should be respected and adhered to for the sake of the children, if for no one else.

Share this article on WhatsApp:

Previous articleThe News ‘NOT FIT TO PRINT” in Mainstream Media
Next articleA Reply to my Critics
Hana Levi Julian is a Middle East news analyst with a degree in Mass Communication and Journalism from Southern Connecticut State University. A past columnist with The Jewish Press and senior editor at Arutz 7, Ms. Julian has written for, and other media outlets, in addition to her years working in broadcast journalism.