SLR - August 2020 - Casey A. Lewis

Classification of the Cutaneous Manifestations of Covid-19:  A Rapid Prospective Nationwide Consensus Study in Spain with 375 Cases

Reference: Galvin Casas C, Catala A, et al. Classification of the Cutaneous Manifestations of Covid-19:  A Rapid Prospective Nationwide Consensus Study in Spain with 375 Cases. British Journal of Dermatology. 2020; doi 10.1111/bjd.19163.

Scientific Literature Review

Reviewed By:  Casey A. Lewis, DPM 
Residency Program:  Beth Israel Deaconess Medical Center – Boston, MA

Podiatric Relevance: As clinical and epidemiological information on the COVID-19 pandemic evolves, healthcare providers hope to discover markers that are predictive or prognostic of the severity of disease. There has been much discussion among podiatry and dermatology communities over cutaneous manifestations of SARS-CoV-2 infection, with particular attention to acral lesions or “COVID toes”, which may be discovered upon a routine clinic visit. The following study sought to describe distinct clinical patterns that would prove representative of and helpful in the early detection of COVID-19. 

Methods: As of April 2020, the WHO considered Spain a significant area of SARS-CoV-2 transmission, and a group of Spanish dermatologists were asked to include patients with suspected or confirmed COVID-19 over a two-week period. A standardized questionnaire and pictures were taken for a group of 375 patients. Pictures were independently reviewed by a group of dermatologists blinded to clinical data, and a consensus was formulated on five main cutaneous patterns. These patterns were then applied to the body of clinical information for further breakdown.

Results:
Five major clinical patterns emerged from photograph analysis:  
- Maculopapules +/- purpura or pityriasis, often resembling erythema elevatum or multiforme comprised 47 percent of cases. Lesions lasted a mean of 8.6 days, appeared at the same time as other symptoms, and were associated with more severe disease (2 percent mortality).  
- Acral areas of erythema-edema with vesicles or pustules (pseudo-chillblain) comprised 19 percent of cases. These usually presented asymmetrically on the hands and feet. Lesions typically affected younger patients, lasted a mean of 12.7 days, arose later in the course of disease, and were associated with lesser disease severity. Only 1/71 patients had a prior history of perniosis.  
- Urticarial lesions comprised 19 percent of cases, often on the trunk but also on palmar surfaces. Lasted a mean of 6.8 days, and appeared at the same time as other symptoms. This group proved more difficult to analyze as urticaria is a non-specific symptom. 
- Vesicular eruptions, largely affecting the limbs, comprised 9 percent of cases, and were often diffuse and hemorrhagic. Typically appeared in middle-aged patients, lasted a mean of 10.4 days, associated with medium severity.  
- Livedo or necrosis, largely acral ischemia, suggestive of occlusive vascular disease was noted in 6 percent of cases. Associated with most severe disease in terms of subsequent hospital and ICU requirements (10 percent mortality).  

Conclusions: The main strength of this large study is the description of common cutaneous patterns based only on morphology, with correlation to the more global clinical picture. While urticarial and maculopapular lesions have many common causes, the authors believed that pseudo-chillblain and vesicular lesions may be more useful indicators of disease, and potentially aid in the early detection of COVID-19. 

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