There have been other reports of urticaria affecting various regions of the body in patients of all age groups infected with COVID-19. One study by Recalcati found urticaria in 3 of 88 COVID-19 patients. They occur due to a variety of causes and have been documented to occur with COVID-19. Urticaria presents with acute, swollen, red wheals or plaques, typically associated with pruritis ( Fig. Raynaud's phenomenon, systemic lupus erythematosus, systemic sclerosis, Buerger's diseaseĪntiphospholipid antibody syndrome, Sneddon syndrome, cryoglobulinemia, multiple myeloma, disseminated intravascular coagulation, hemolytic uremic syndrome, deep venous thrombosis, systemic lupus erythematosus, rheumatoid arthritis, polyarteritis nodosa, Sjogren's syndrome, multiple sclerosis, Parkinson's disease, cancer (e.g., renal cell cancer, breast cancer, lymphoma, leukemia)Īrterial ischemia, disseminated intravascular coagulation, Buerger's disease Thrombocytopenia, systemic lupus erythematosus, leukemia, disseminated intravascular coagulation, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, vasculitis, vitamin C deficiency Varicella zoster (i.e., chickenpox), herpes zoster (i.e., shingles), herpes simplex, Rhus dermatitis (e.g., poison ivy, poison oak, poison sumac), pemphigoid Viral exanthem, Scarlet fever, measles, rubella, medication reaction, secondary syphilis, heat rash, leukemia, graft-versus-host diseaseĪllergic reaction, anaphylaxis, angioedema, autoimmune disease (e.g., systemic lupus erythematosus), hypereosinophilia, chronic urticaria, malignancy However, it is important to consider COVID-19, especially in the patient with upper respiratory or systemic symptoms ( Table 1 Many of these rashes have a broad differential diagnosis. Ī challenging aspect of rash associated with COVID-19 is the myriad types of presentation. Pruritus is often minimal but depends on the type of rash, and lesions typically heal quickly, appearing within 3 days and disappearing within 8 days. Ī rash associated with COVID-19 can involve various body regions, most commonly the trunk, but extremity involvement may also occur. This has been based on high concentrations of lymphocytes without eosinophils, papillary dermal edema, epidermal spongiosis, and lymphohistiocytic infiltrates. Others have suggested that this occurs as a direct effect of the virus. One study found significant complement protein deposition in the dermal capillaries, as well as interstitial and perivascular neutrophilia with prominent leukocytoclasia, suggesting a vasculitic phenomenon. The first is diffuse microvascular vasculitis, resulting from complement system activation. There are several proposed etiologies for rash in patients with COVID-19. A more recent study found rash occurred in 18 of 88 patients, with 8 of these patients having rash at onset, while another study found that rash occurred in 5 out of 103 patients. One early study found that only 2 of 1099 patients had a “rash”, but investigators may have missed several patients. While the most common symptoms of COVID-19 include congestion, cough, dyspnea, and fever, skin symptoms can occur in up to 20.4% of patients. These signs and symptoms may assist clinicians in considering the disease before the development of respiratory symptoms and may also be used to identify complications requiring treatment. Some case reports have noted that dermatologic findings may present prior to respiratory symptoms, though most studies suggest skin manifestations present several days after the onset of other symptoms, , ]. Recent literature suggests ACE2 is also located in the skin, which may explain some of the dermatologic manifestations in the setting of COVID-19 infection. These factors can result in multiorgan dysfunction. SARS-CoV-2 may cause direct lung injury and systemic inflammation, as well as increased coagulation, , ]. ACE2 plays several key roles in normal physiology, including breakdown of angiotensin II. SARS-CoV-2 is an RNA virus that may enter cells through the angiotensin-converting enzyme 2 (ACE2) receptor found on lung alveolar epithelial cells, small intestine enterocytes, and vasculature, as well as neurologic, endocrine, and cardiac systems.
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