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Covid-19 and the skin



My first symptom of acute Covid -19 was feeling really cold all day. By the evening I had an intensely itchy red rash on my back between my shoulder blades. A few hours later I had a fever of 38 degrees.

This rash stayed with me throughout my acute illness, about 3 weeks. However it came back multiple times throughout the next 6 months. I thought maybe it was a heat rash as I was spiking to 38 degrees several times a day but sometimes the rash occurred sporadically and was not always associated with a fever.

In those first few weeks I also developed multiple petechiae on my upper arms, chest and abdomen.

There were profuse Campbell de Morgan spots appearing all over my lower chest and abdomen.

My tongue was swollen and red and there were multiple sores on it. I had strange burst blood vessels on the soft palate of my mouth.

Since then I have had intermittent intensely itchy skin - mainly my arms, I bruise really easily on my legs, sometimes have clear vesicles on the soft palate of my mouth and regularly get "hockey legs" - levido reticularis. By all accounts I got off quite lightly when it comes to Covid -19 skin symptoms. Oh apart from the frequent painful mouth ulcers….

Skins rashes in acute Covid-19:

In the paper, "Covid-19 skin rashes may hold the key to diagnosis", British Journal of Dermatology, January 2021, King’s College researchers analysed data from 336,847 UK users of the Zoe COVID Symptom Study app to evaluate the potential of using skin rashes in the diagnosis of SARS-CoV-2 infection. At the same time, an independent online survey was conducted with 11,546 respondents to collect data on skin-specific symptoms of COVID-19. They found that

The presence of skin rashes was significantly associated with a greater likelihood of a positive SARS-CoV-2 swab test result.

Body rashes appeared more frequently than those on the hands and feet; 7%: 3% respectively.

The findings of the online survey showed that:

17% of SARS-CoV-2-positive respondents had skin rashes as the first presentation and 21% reported rashes as the only COVID-19 clinical sign.

The authors in collaboration with the British Association of Dermatologists have curated a catalogue of 400 images of the most common cutaneous manifestations of COVID-19. The catalogue is publicly available at https://covidskinsigns.com. Feel free to send your photos in!


Dr Bataille, a consultant dermatologist and co-author on the research stated:

"Many viral infections can affect the skin, so it's not surprising that we are seeing these rashes in COVID-19. However, it's important that people know that in some cases, a rash may be the first or only symptom of the disease. So if you notice a new rash, you should take it seriously by self-isolating and getting tested as soon as possible.”

This research has lead those behind the study to call for skin rashes to be included as a fourth key symptom of COVID-19.


The study said rashes associated with acute COVID-19 fell into three categories:

1. Urticaria or hive-type rash:

  • The sudden appearance of raised bumps on the skin, which come and go quite quickly over hours, and are usually very itchy.

  • It can involve any part of the body, and often starts with intense itching of the palms or soles, and can cause swelling of the lips and eyelids.

  • These rashes can present quite early on in the infection, but can also last a long time afterwards.


2. 'Prickly heat' or chickenpox-type rash:

  • Areas of small, itchy red bumps that can occur anywhere on the body, but particularly the elbows and knees as well as the back of the hands and feet.

The rash can persist for days or weeks


3. Morbiliform rash aka COVID fingers and toes:

  • Reddish and purplish bumps on the fingers or toes, which may be sore but not usually itchy. Resemble chilblains

  • This type of rash is most specific to COVID-19, is more common in younger people with the disease, it can occur in the acute infection but also can present later on

  • Thought to be due to vascular injury caused by the virus

Tim Spector has recently tweeted about Covid tongue also occurring in the acute Covid-19 infection with many reporting swollen tongues, tongue discolouration, and mouth ulcers. This like rashes may be a presenting symptom for some.

Long Covid Rashes


So research has identified hives, prickly heat and Covid fingers and toes as rashes that occur in the acute Covid-19 infection. Many continue to have these three symptoms for many, many months. Also other rashes do occur. Here are some others I have identified through FB support groups and my own research:


Levido reticularis:

A mottled lace-like eruption. Venules are small veins that collect blood from capillaries. When capillaries are obstructed by tiny blood clots, venules swell and become visible. Livedo reticularis is also associated with abnormal superficial circulation and spasms of blood vessels. It typically appears when body temperature drops and clears when the patient warms up. Can be due to underlying vascular disease.

Retiform purpura:

Purple coloured mottling with leakage of blood. Retiform purpura results from either blood vessel wall damage or occlusion of the vessel lumen causing complete vessel obstruction and skin ischaemia downstream. It can be due to small vessel vasculitis. It is a non-blanching rash so urgent medical care must be sought if the patient is unwell.


Acute urticaria:

Weals or hives can be a few millimetres or several centimetres in diameter, coloured white or red, with or without a red flare. Each weal may last a few minutes or several hours and may change shape. Weals may be round, or form rings, a map-like pattern, look like targets, or giant patches. Acute urticaria can affect any site of the body and tends to be distributed widely. They can be present with Mast Cell Activation Syndrome (MCAS).

Vesicular chickenpox-like blisters:


Shingles rash:

With our immune system having been under attack for so long and so harshly it is severely weakened. This is when reactivation of the chicken pox virus or shingles can occur. It can look very much like prickly heat initially but will develop vesicles and then crust over. This is intensely painful, can be itchy and is an emergency if it's anywhere near the eyes.

Vesicles on soft palate of the mouth could be oral shingles, it could be reactivation of a previous viral illness, or most likely some form of Long Covid shenanigans.

Easy Bruising:

This is more likely to occur if you are older, a woman or have a family history of bruising. Tends to occur on the lower limbs. Most likely a sign that your spleen is underperforming. Your spleen has been in a boxing match for months fighting off Covid -19 trying too make as many virus fighting cells as possible but also to make platelets and clotting factors to boost our clotting system. The clotting system takes second place in this scenario and bruises occur.

Petechiae:

Purpura is the name given to the discolouration of the skin or mucous membranes due to haemorrhage from small blood vessels. Petechiae are the most commonly seen purpura and these are small at 2mm across. Again, like the bruising, these are due to damage to the platelet cells but can also be a result of leaky small blood vessels. This is also a non-blanching rash so if you or your child are unwell with this rash you must seek urgent medical help.


Campbell de Morgan / cherry angioma:

A totally benign and common skin lesion as we age. I did have 100’s of these appear in the acute stage of Covid-19 (and also have felt like I have aged 20 years) so would be interested to know if anyone else developed these?!


Angioedema:

This is swelling, often localised. It commonly affects the face (especially the eyelids and around the mouth), hands, feet and genitalia. It may involve tongue, uvula, soft palate and larynx. Angioedema is often the result of an allergic reaction.

This is where the body mistakes a harmless substance, such as a certain food, for something dangerous. It releases chemicals into the body to attack the substance, which cause the skin to swell. Many people with Long Covid have developed new allergies and has been linked to MCAS.

Similarly intensely itchy skin may be due to high histamine levels


Telogen effluvium:

Hair loss that occurs in the recovery phase. Please see my previous post https://www.rosecottagedoc.co.uk/post/hair-loss-after-covid-19

Red half-moon nail sign:

Transverse red bands are seen on the nails after a SARS‐CoV‐2 infection. It is thought that there is a localized microvascular injury secondary to inflammatory immune response and a pro clotting state might be the reason. There may be damage of the capillary network of the distal nail bed.


Multi-system inflammatory syndrome in children:


Multi-system inflammatory syndrome in children (MIS-C) is a serious condition linked to COVID-19. Most children who become infected with the COVID-19 virus have only a mild illness. But in children who go on to develop MIS-C, some organs and tissues — such as the heart, lungs, blood vessels, kidneys, digestive system, brain, skin or eyes — become severely inflamed. Signs and symptoms depend on which areas of the body are affected. If you are concerned about an ill child always seek medical help.


Covid tongue:


So that's my whistle stop tour of skin manifestations in Covid-19. If you have heard of or seen any others please let me know.



References

https://www.univadis.co.uk/viewarticle/covid-19-skin-rashes-may-hold-key-to-diagnosis-737194?uuid=af644369-a558-39ee-a763-4cb5bb34517b&u=g7Nnk16ewgtSi3Ivdd2czPWkGsoYzBW4Qd36JL77Z222MZ%2Bd%2F7nw9dbkeBD%2BzOpe&ecd=wnl_gps_210121_uniday_MUDUK_4524239&utm_source=newsletter%20email&utm_medium=email&utm_campaign=medical%20updates%20-%20daily%202.5%20gps&utm_content=4524239&utm_term=automated_daily

https://dermnetnz.org/topics/covid-19/

https://www.medscape.com/viewarticle/930180


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