Cutaneous manifestations of the Coronavirus Disease 2019 (COVID‐19): A brief review

COVID‐19, first appeared in December 2019 in Wuhan, China, has been spreading quickly throughout the world. We reviewed the evidence on cutaneous manifestations of COVID‐19 based on PubMed database. The searching strategy was (COVID* or coronavirus*) and (dermatol* or skin* or cutaneous*). The publication time was limited to 2019 onward. After independent review by two authors, 14 studies with 228 confirmed cases were included in the analysis. A total of 60 patients developed skin rashes, and the age ranged from 8 to 84. Exanthematous eruptions potentially related to COVID‐19 infection were highly variable and heterogeneous. Skin lesions mainly appeared erythematous, urticarial, and vesicular (chicken pox‐like or varicelliform). Petechiae rash, livedo reticularis, and reactivation of oral HSV‐1 were also observed in single cases. Newly reported eruptions like vascular lesions and peculiar (perniosis‐like) skin lesions caused concern among dermatologists. Exanthems were widely distributed and were primarily located on the trunk. Associated symptoms, latency time, treatment, and prognosis were also carefully summarized. This study reviewed the recently published COVID‐19 studies with skin manifestations, which may pave the way for further research.     

Cutaneous manifestations of COVID‐19: A review of the published literature

COVID‐19 is a highly contagious respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2. COVID‐19 outbreak, which caused thousands of deaths, has been declared a pandemic by the World Health Organization in March 2020. The infection has been reported to demonstrate different types of cutaneous manifestations including urticarial, maculopapular, papulovesicular, purpuric, livedoid, and thrombotic‐ischemic lesions. Given the high mortality rate of the infection, timely and accurate identification of relevant cutaneous manifestations may play a key role in the early diagnosis and management. In this study, we provide a review with a focus on the reported cutaneous manifestations of COVID‐19.     

Contributions of dermatologists to COVID‐19 research: A brief systematic review

Coronavirus disease 2019 (COVID‐19) has been declared a pandemic. We conducted a systematic review to reveal the contribution of dermatologists in COVID‐19 research. Two hundred and ninety‐eight articles were included and classified into cutaneous manifestations of COVID‐19, operating experience against COVID‐19, mechanisms and treatment of COVID‐19, disinfection and personal protective equipment (PPE)‐related skin diseases, and other topics. The value of these articles and their impact on clinical impact were discussed and we hope that dermatologists can have a better understanding of these areas from this study.     

Oral manifestations of COVID‐19 disease: A review article

Dysgeusia is the first recognized oral symptom of novel coronavirus disease (COVID‐19). In this review article, we described oral lesions of COVID‐19 patients. We searched PubMed library and Google Scholar for published literature since December 2019 until September 2020. Finally, we selected 35 articles including case reports, case series and letters to editor. Oral manifestations included ulcer, erosion, bulla, vesicle, pustule, fissured or depapillated tongue, macule, papule, plaque, pigmentation, halitosis, whitish areas, hemorrhagic crust, necrosis, petechiae, swelling, erythema, and spontaneous bleeding. The most common sites of involvement in descending order were tongue (38%), labial mucosa (26%), and palate (22%). Suggested diagnoses of the lesions were aphthous stomatitis, herpetiform lesions, candidiasis, vasculitis, Kawasaki‐like, EM‐like, mucositis, drug eruption, necrotizing periodontal disease, angina bullosa‐like, angular cheilitis, atypical Sweet syndrome, and Melkerson‐Rosenthal syndrome. Oral lesions were symptomatic in 68% of the cases. Oral lesions were nearly equal in both genders (49% female and 51% male). Patients with older age and higher severity of COVID‐19 disease had more widespread and sever oral lesions. Lack of oral hygiene, opportunistic infections, stress, immunosuppression, vasculitis, and hyper‐inflammatory response secondary to COVID‐19 are the most important predisposing factors for onset of oral lesions in COVID‐19 patients.     

Novel coronavirus disease 2019 (COVID‐19) and neurodegenerative disorders

During the last few months, the whole humanity is experiencing largest and most severe sudden influx of COVID‐19 outbreak caused by the novel coronavirus (CoV) originated from Wuhan, China. According to the WHO reports, total 3 862 676 positive cases and 265 961 deaths have been recorded worldwide due to COVID‐19 infection as of May 9, 2020. CoVs are a large family of viruses (enveloped, single‐stranded RNA viruses), which includes severe acute respiratory syndrome coronavirus (SARS‐CoV) and Middle East respiratory syndrome‐related coronavirus (MERS‐CoV). New SARS CoV2 is the members of Betacoronavirus genus. These viruses cause infections in bats, camels and humans, and a few other associated species. Despite many neurologic complications associated with SARS‐CoV‐2 infection, it is still unclear whether these symptoms results from direct neural injury or due to some other reason. Currently, it appears that most of the neurological symptoms of COVID‐19 are nonspecific and secondary to the systemic illness. A single case of acute hemorrhagic necrotizing encephalopathy has been reported. SARS‐CoV‐2 associated Guillain‐Barré syndrome is an atypical case. Till today, no convincing evidence is available to confirm that the SARS‐CoV‐2 virus directly affects nerves system in humans. However, postinfection surveillance will be necessary to identify the possible post‐COVID‐19 neurologic syndromes.     

Management of urticaria in COVID‐19 patients: A systematic review

The global pandemic COVID‐19 has resulted in significant global morbidity, mortality and increased healthcare demands. There is now emerging evidence of patients experiencing urticaria. We sought to systematically review current evidence, critique the literature, and present our findings. Allowing PRISMA guidelines, a comprehensive literature search was carried out with Medline, EMBASE, Scopus, Cochrane, and Google Scholar, using key MeSH words, which include “COVID‐19,” “Coronavirus,” “SARS‐Cov‐2,” “Urticaria,” “Angioedema,” and “Skin rash” up to 01 August 2020. The key inclusion criteria were articles that reported on urticaria and/or angioedema due to COVID‐19 infection and reported management and outcome. Studies were excluded if no case or cohort outcomes were observed. Our search returned 169 articles, 25 of which met inclusion criteria. All studies were case reports, reporting 26 patients with urticaria and/or angioedema, COVID‐19 infection and their management and/or response. ajority of patients (n = 16, 69%) were over 50 years old. However, urticaria in the younger ages was not uncommon, with reported case of 2 months old infant. Skin lesions resolved from less than 24 hours to up to 2 weeks following treatment with antihistamines and/or steroids. There have been no cases of recurrent urticaria or cases nonresponsive to steroids. Management of urticarial in COVID‐19 patients should involve antihistamines. Low dose prednisolone should be considered on an individualized basis. Further research is required in understanding urticarial pathogenesis in COVID‐19. This will aid early diagnostic assessment in patients with high index of suspicion and subsequent management in the acute phase.     

Surveillance of psoriatic patients on biologic treatment during the COVID‐19 pandemic: A single‐center experience

There are few studies on how patients with psoriasis who are on biologic therapy are affected by the COVID‐19 pandemic. We analyzed the impact of the COVID‐19 pandemic on patients with psoriasis receiving biologic therapy, patients' current status at a single center in Turkey. A total of 133 patients (mean age; 44.6 ± 13.5 years) were on maintenance biological treatment for moderate‐to‐severe psoriasis during the pandemic. A standardized questionnaire was administered by phone interviews to determine patients' perceptions, attitudes, and adherence to therapy and identify the frequency of COVID‐19 infection, psoriasis status, and new comorbidities during the pandemic. All patients had been receiving a biological agent including ustekinumab, etanercept, adalimumab, secukinumab, infliximab, ixekizumab, or certolizumab pegol. Ninety‐one patients (68.4%) had at least one comorbid condition, including psoriatic arthritis (35.3%), hypertension (19.5%), diabetes mellitus (16.5%), obesity, coronary artery disease, and dyslipidemia. During the first 3 months of the pandemic, 52 patients (39%) suspended their biological therapies for short (n = 33) or long (n = 19) periods without medical advice for reasons of fear, worry, and anxiety. All but one patient restarted their medications as a result of therapeutic counseling. Five patients reported suspicious symptoms, but only one had PCR‐confirmed COVID‐19. Our findings suggest that biologic treatment for moderate‐to‐severe psoriasis would not pose an additional risk for COVID‐19 infection and its life‐threatening complications, even in the presence of a high frequency of cardiometabolic comorbidities, provided that all patients are informed and necessary pandemic‐directed precautions are well adopted by the patients.     

Six months into the pandemic. A review of skin manifestations in SARS‐CoV‐2 infection

During the COVID‐19 pandemic, various cutaneous manifestations have been described as associated with SARS‐CoV2 infection. It is debated if skin lesions could represent a diagnostic or prognostic indicator. Specifically, it is unclear whether skin lesions may be used to perform an early diagnosis and/or to predict worse outcomes. In this review, we described the cutaneous signs so far reported as COVID‐19‐related and discussed their incidence, clinico‐pathological features, and diagnostic and prognostic value.     

Back to the basics: Propolis and COVID‐19

The epidemiological burden of COVID‐19 is a healthcare challenge throughout the world, not only in terms of testing the limits of medical capacities, but also as an enigma considering preventive strategies and methods. The upper respiratory tract mucosa is the first line of defense, as a physical barrier, as well as through multiple innate and adaptive immune mechanisms which are crucial for efficient antiviral responses. Identifying methods able to reduce or prevent colonization, viral adhesion, and promote virus shedding on mucous membranes or have the ability to inactivate pathogens and thus reduce virus dose and/or increase immune response would be essential in the management of COVID‐19 outbreak and help in flattening the curve. We review the effects of propolis, an old remedy with proven antiviral properties, as a possible low‐cost inhibitor of SARS‐CoV‐2 in the oropharyngeal niche, prophylaxis, or adjuvant therapy.     

Rituximab as the treatment of pemphigus vulgaris in the COVID‐19 pandemic era: A narrative review

Pemphigus vulgaris (PV), an autoimmune blistering disease is treated with immunosuppressive medications. As the immunosuppressive effect of rituximab, the first‐line therapy of PV, lasts more than 6 months, many concerns have raised due to the ongoing novel coronavirus disease (COVID‐19) pandemic. With this background, our objective was to review the currently available literature as well as important websites for the evidence related to rituximab, PV and COVID‐19, adverse effects associated with drugs, and relevant guidelines. “PubMed” and “Google Scholar” database were systematically searched for retrieving all articles related to anti‐CD20 therapy in pemphigus vulgaris and COVID‐19 published up to 14 July 2020. A total of seven clinical studies are performed with anti‐CD20 therapy in COVID‐19, three of which are performed on pemphigus patients, and have shown concerns employing rituximab in patients with COVID‐19. Evidence for treating PV patients with rituximab in COVID‐19 pandemic is limited. Until sufficient evidence or guideline for pemphigus and COVID‐19 treatment is available, we advocate caution commencing rituximab in patients with pemphigus, due to the reported adverse outcomes.     

Restructuring an academic dermatology practice during the COVID‐19 pandemic

Severe acute respiratory syndrome coronavirus 2 is a highly virulent positive‐sense single stranded RNA virus that spreads rapidly via respiratory droplets, causing severe acute respiratory syndromes with significant mortality and morbidity. Currently 210 countries and territories are affected around the world with a reported 2.6 million confirmed cases. The coronavirus disease 2019 pandemic has changed the way patients attend their specialist appointments and receive medical care. While some specialist clinics have closed we have implemented strategies and restructured our academic practice in Australia to minimize the spread of disease while treating patients who need urgent care. We hope to share these strategies in the hope they may be useful to the dermatology community.     

Noncutaneous considerations of COVID‐19 for dermatology practices

COVID‐19 presents many pressing challenges to the global dermatological community and our patients with ongoing skin needs, which must be considered by every dermatology provider. Many of these are logistical and administrative, distinct from physical manifestations, and could be summarized by the acronym COVID (Consultations, Operations, Videoconferencing, Immunosuppressive medications, Drug and equipment shortages). While the pandemic may represent a threat to many parts of our existence, dermatologists can help the patients we care for by considering noncutaneous implications of COVID‐19 upon our practice.     

COVID‐19 knowledge prevents biologics discontinuation: Data from an Italian multicenter survey during RED‐ZONE declaration

SARS‐CoV‐2 become pandemics and there is still a dearth of data about its the potentially among dermatological patients under biologics. We aimed to assess health literacy, disease knowledge, treatment dissatisfaction and biologics attitudes toward COVID‐19. We performed a cross‐sectional, questionnaire‐based survey on 98/105 consecutive dermatological patients treated with biologics—51 suffering from plaque psoriasis, 22 from atopic dermatitis, and 25 from hidradenitis suppurativa. An ad hoc, validated questionnaire has 44 items investigating the following domains: knowledge of COVID‐19 related to (a) epidemiology, (b) pathogenesis, (c) clinical symptoms, (d) preventive measures, and (e) attitudes. Patients data and questionnaires were collected. Despite only 8.1% thought that biologics may increase the risk of COVID‐19, 18.4% and 21.4% of the patients were evaluating the possibility to discontinue or modify the dosage of the current biologic therapy, respectively. Globally, male patients (P = .001) with higher scholarity level (P = .005) displayed higher knowledge of COVID‐19. Patients with lower DLQI (P = .006), longer disease duration (P = .051) and lower scholarity (P = .007) have thought to discontinue/modify autonomously their biologic therapy. At the multivariate logistic regression, only the knowledge of epidemiology and preventive measures resulted independent predictors of continuation vs discontinuation and modification vs no modification, respectively. Dermatologists should promote COVID‐19 knowledge to prevent biologics disruption.     

Treatment considerations for Behçet disease in the era of COVID‐19: A narrative review

COVID‐19 is a multisystem disease caused by severe acute respiratory syndrome coronavirus 2. It has been declared a pandemic by the World Health Organization in March 2020 and the outbreak still keeps its impacts worldwide. Behçet disease (BD) is a multi‐systemic vasculitis involving the skin, mucosa, eyes, joints, nervous system, cardiovascular system, and gastrointestinal system. The precise etiopathogenesis of the disorder is unknown but autoimmunity is believed to play a key role. A considerable part of patients with BD are susceptible to immunosuppression and are more predisposed to infections than healthy individuals. Hence, the protection and control measures for patients with BD against the COVID‐19 are of the utmost significance. Given the requirement to balance proper treatment of BD with the smallest risk of COVID‐19 associated mortality and morbidity, we aimed to review the management of BD in the era of the pandemic with a special focus on treatment considerations. According to current expert recommendations, there is no reason to discontinue topical treatments, colchicine, and nonsteroidal antiinflammatory drugs. Systemic steroids can be used at the lowest possible dose if needed. Ongoing treatments can be continued unchanged in patients with no suspected or confirmed COVID‐19. In cases with COVID‐19 symptoms, immunosuppressive and biological agents can be temporarily stopped but the decision should be made on a case by case basis. Considering their potential beneficial effects on the course of COVID‐19, colchicine, pentoxifylline, and dapsone can be considered as safe treatment options in BD.     

COVID‐19 Pandemic: Consensus guidelines for preferred practices in an aesthetic clinic

Strict infection control measures in response to the current COVID‐19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS‐CoV‐2 infection. Consensus guidelines for “preferred practices” were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized into low‐risk, moderate risk, and high‐risk based on the likelihood of transmission of SARS‐CoV‐2 virus from the patient to the treating physician or therapist. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID‐19 infection in aesthetic clinics.