Dear Editor,
Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO) on March 11, 2020.[1] Incidence of cutaneous manifestations has been varied and reported the incidence as high as 20.4%.[2] A retrospective study was performed at a COVID-19 designated hospital in New Delhi on all confirmed COVID-19 infected patients admitted from April 13, 2020 to August 31, 2020 during the second and the severest wave responsible for a maximum number of admissions and deaths. All clinical case notes, recording or describing any dermatological findings were checked. Records of any call given to dermatology residents or specialists were also checked and verified. A total of 1536 cases were admitted during the study period. There were only three cases (0.19%) who had developed cutaneous lesions which could be attributed to COVID-19 infection. First was a case of acute urticaria in a 43-year-old male. Second case was a 37-year-old lady who developed morbilliform rash. Third patient was a 32-year-old lady who developed palpable purpura which was confirmed as a case of leukocytoclastic vasculitis by biopsy.
Even though there is uncertainty about the incidence of cutaneous manifestations due to COVID-19 infection, the literature particularly involving Caucasian population have extensively covered the various aspects of cutaneous manifestations. Studies have even tried to classify the types of clinical patterns of COVID-19-associated cutaneous manifestations.[3] To our surprise, only three cases (0.19%) had specific cutaneous lesions attributed to COVID19 infection in this study. This is very low in comparison to published reports across the world. There are very limited studies from India on cutaneous manifestations of COVID-19 infection. A study by Dalal et al.[4] from North India [Table 1] also had a higher number in comparison to this study. However, a large number of patients had pruritus in this study, which is a nonspecific cutaneous manifestation. Another study by Goyal et al.[5] conducted at a tertiary care center in South India reported three cases having cutaneous manifestations of COVID-19, namely maculopapular rash, urticaria, and herpes zoster; however, this study did not mention the total number of COVID-19 infected patients. In this retrospective study of 1536 COVID-19 patients, belonging to all age groups, only three cases that had significant cutaneous lesions were found. It cannot be said with certainty what was the reason for such a low incidence of cutaneous manifestations in our subset of patients. Different ethnicity, early intervention with an antiviral regimen, and systemic steroids could be speculative explanations. A comparison to similar set of population on a larger scale is required to know the exact cause of such low incidence. Overall, the cutaneous manifestations of COVID-19 infection appear to be an overhyped concept for at least the Indian population.
Table 1.
Illustrating the various types of cutaneous manifestation observed in different studies with their percentage of occurrence and country of study.
| Authors with number of patients studied | Urticarial rash Number (%) | Confluent erythematous/maculopapular/morbilliform rash Number (%) | Papulo-vesicular exanthem Number (%) | Chilblain-like acral pattern Number (%) | Livedo reticularis/racemosa-like pattern Number (%) | Purpuric/“vasculitic/Pattern Number (%) | Country of study |
|---|---|---|---|---|---|---|---|
| Askin et al.6 (52) | 7 (13.5) | 29 (55.8) | 3 (5.8) | 1 (1.9) | 0 | 8 (15.4) | Turkey |
| Galván Casas et al.7 (375) | 73 (19) | 176 (47) | 34 (9) | 71 (19) | 0 | 21 (6) | Spain |
| De Giorgi et al.8 (53) | 14 (26) | 37 (70) | 2 (4) | 0 | 0 | 0 | China, Italy |
| Freeman et al.9 (716) | 55 (8.1) | 115 (16.1) | 49 (7.2) | 422 (62) | 46 (6.4) | 51 (7.1) | Multinational (eight countries) |
| Dalal et al.4 (102) | 2 (1.9%) | 3 (2.9%) | 0 | 0 | 0 | 0 | North India 8 (7.8%) had pruritus |
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References
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