Recognizable vascular skin manifestations of SARS‐CoV‐2 (COVID‐19) infection are uncommon in patients with darker skin phototypes

Reported cutaneous manifestations of SARS‐Cov‐2 infection include maculopapular rash, urticarial rash, varicelliform or vesicular lesions, petechiae/purpura, livedoid/necrotic lesions, chilblain‐like lesions (‘COVID toes’), erythema multiforme‐like lesions¹ and aphthous ulcers.² These cutaneous manifestations have been mostly reported from countries with populations of lighter skin phototypes, with a paucity of data from the populations with darker skin phototypes.³ We conducted a prospective study to report the prevalence and patterns of cutaneous manifestations in patients with COVID‐19 from India.

We included all patients in an inpatient department at a dedicated centre for COVID‐19‐positive patients at the All India Institute of Medical Sciences, India from 11 June to 10 July 2020. The patients were admitted following a positive PCR reaction for COVID‐19. All the inpatients were screened for any cutaneous lesions by a single dermatologist (RP).

Of 138 patients admitted in a 30‐day period, 10 (7.25%) had cutaneous manifestations (Table 1). All 10 patients had Fitzpatrick skin types IV or V. In all our patients, the cutaneous features followed the symptoms of COVID‐19.

Table 1.

Details of the patients possible COVID‐19‐related cutaneous features included in the study.

Patient	Age, years	Sex	Lesion morphology/diagnosis	Site(s)	Duration	Severity of COVID‐19 symptoms	Comorbidities	Other relevant features/comments
1	54	F	Weals	Limbs	2 days	Mild	None	No prior history of weals. The patient also reported a burning sensation over the palms and soles
2	24	M	Desquamation	Palms and soles	4 days	Mild	AML	Desquamation started just after resolution of fever
3	59	F	Weals	Limbs, trunk	7 days	Mild	DM	No prior history of weals
4	31	M	Petechiae	Trunk	3 days	Severe	CML	–
5	19	M	Purpura	Arms and legs	4–5 h	Moderate	None	No thrombocytopenia. Patient died after 1 day of admission
6	40	M	Purpura	Periumbilical area and flank	7 days	Severe	Acute on chronic liver failure	Thrombocytopenia
7	50	F	Chilblain‐like	Toes of both feet	15 days	Mild	DM	Lower limb ischaemia as documented by Doppler ultrasonography
8	55	M	Weals	Arms	Acute onset for 7 daysa	Mild	Chronic kidney disease, hypothyroidism	–
9	28	M	Minor aphthous ulcers	Oral cavity	4 days	Mild	None	No prior history of recurrent oral aphthosis
10	39	M	Macular erythematous rash	Face, trunk	3 days	Mild	DM, hypertension	Occurred in the resolving phase

AML, acute myeloid leukaemia; CML, chronic myeloid leukaemia; DM, diabetes mellitus;

^a patient already had a 2‐year history of chronic weals, but the acute episode, lasting for 7 days, correlated temporally with his COVID‐19 diagnosis.

We devised the following criteria to distinguish COVID‐19‐related cutaneous manifestations from incidental or unrelated skin findings. The major criterion was a temporal correlation with the onset of COVID‐19 symptoms or positivity, with a range of −2 to 21 days from systemic symptoms; this range was decided on after analysing the various cases reported in the literature.⁴ Minor criteria were (i) resemblance to the previously reported cutaneous features of COVID‐19, and (ii) no other plausible explanation for the skin lesions. For inclusion, the major criterion and at least one of the two minor criteria had to be present. Using these criteria, all 10 patients were judged to have COVID‐19‐related lesions (Table 1). Some of the presenting features are shown in Fig. 1.

Figure 1.

(a) Urticarial lesions in 55‐year‐old man (Patient 8); (b) desquamation of skin over palms and soles of a 24‐year‐old man (Patient 2); (c) chilblain‐like lesions in a 50‐year‐old woman (Patient 7); (d) purpural rash in a 19‐year‐old man (Patient 5).

There seems to be a wide variation in the prevalence of cutaneous manifestations, ranging from 0.2% in a study on Chinese patients,⁵ through 7.25% in our study to 20.4% in a study from Italy.⁶ Reported vascular cutaneous manifestations, such as chilblain‐like lesions, livedoid/necrotic lesions, vasculitis and vasculopathic ulcers, are uncommon in Indian patients. Geographical differences have also been observed in the severity of COVID‐19 symptoms and the mortality rates across various parts of the world, with India having a low case fatality rate. The explanation for this is not known; however, lipoprotein A has been identified to be an independent risk factor for cardiovascular, peripheral arterial and cardiovascular diseases, and impaired fibrinolysis. Levels of lipoprotein A are about twice as high in people of African descent than in white, Hispanic and many Asian populations, whereas only intermediate levels are seen in South Asian populations. In addition, the prevalence of minor allele frequency for Factor V Leiden mutation is higher in whites than in Asians. These differences in thrombophilic genetic conditions could explain the higher frequency of vascular cutaneous manifestations and fatalities in American and European compared with Asian populations.⁷

Recognition of cutaneous features is important for dermatologists, as these may appear before the systemic symptoms or before SARS CoV‐2 positivity is established, or may even be the sole manifestations in systemically asymptomatic patients. This study is limited by its small sample size, but its strength is that the patients were screened by a dermatologist who was directly involved in the care of the COVID‐19 inpatients.