COVID-19 patients may develop skin rashes and discoloration, studies find

Authors: By Jacqueline Howard, CNN | Posted – Aug. 5, 2020 at 2:36 p.m.

CNN — As Covid-19 started to spread across the United States earlier this year, dermatology offices began to see suspicious signs on some patients’ skin: Red or purple toes, itchy hives, mottled bumps on fingers, a lacy red rash that spread across legs and arms.

But were those truly associated with the novel coronavirus? After all, many other factors could be at play.

“Many viral infections can trigger a skin rash, so when you catalog these case reports, you have to have other data. Was the patient on a medication a week before the rash began? Are there other possible causes?” asked Dr. Art Papier, an associate professor of dermatology at the University of Rochester Medical Center in New York.

“This is the challenge that Covid-19 brings up. With these different types of presentations and different rashes, is it hives because the patient just has hives or hives related to Covid-19?”

Case reports began to be released in medical journals. The latest, published Wednesday in the journal JAMA Dermatology, describes the experiences of four patients with severe Covid-19 who were admitted to hospitals in New York City in March and April.

The patients, ages 40 to 80, had discoloration of their skin as well as lesions called retiform purpura, according to the research report.

Biopsies were performed for each patient and they showed that the patients had a type of vasculopathy, meaning that their blood vessels were affected.

The researchers — from NewYork-Presbyterian/Weill Cornell Medical College — wrote in their report that the skin discoloration could represent partial occlusion or blockage of blood vessels, and the retiform purpura could represent full blockage.

Such rashes and discoloration of the skin can be a “clinical clue” to there being possible blood clotting in the body, the study said. Since early on in the pandemic, doctors have noticed that severe Covid-19 could cause abnormal blood clotting in patients.

The report comes with some limitations, including that the researchers were not able to confirm the precise timing of when rashes and other issues with the skin first appeared for each patient. Also, more research is needed to determine whether similar findings would emerge among a larger group of Covid-19 patients.

Yet overall, the researchers wrote in their report that physicians caring for Covid-19 patients should be aware of skin discoloration and rashes as “potential manifestations” of abnormal underlying blood clotting.

‘Many viral infections can affect the skin’

Doctors and researchers from around the world also have reported about other types of skin rashes among Covid-19 patients.

Covid-19 often triggers significant inflammation in its victims, in some cases producing the so-called cytokine storm that appears to be causing the worst damage in advanced patients.

The skin is particularly sensitive to inflammation, said board certified dermatologist Dr. Seemal Desai, a spokesperson for the American Academy of Dermatology.

“The cytokines that are cranking up the immune engine of the car is what then triggers a variety of these immune molecules to go into the skin and wreak havoc on the skin,” said Desai, a dermatologist in Plano, Texas.

In July, researchers from King’s College London in the United Kingdom called for skin rashes and “Covid fingers and toes” to be considered as a key symptom of Covid-19, even arguing that they can occur in the absence of any other symptoms.

Key coronavirus symptoms that are widely accepted include fever, cough and shortness of breath, but a range of other signs have been suggested. The loss of smell and taste, another outlier, was recently included on the list of most common symptoms by the US Centers for Disease Control and Prevention.

The Kings College researchers used data from the Covid-19 Symptom Study app, which is submitted by around 336,000 people in the UK. They found that 8.8% of people who tested positive for coronavirus reported a skin rash as a symptom, compared with 5.4% of people who tested negative.

The KLC team then set up a separate online survey, gathering information from nearly 12,000 people with skin rashes and suspected or confirmed Covid-19. The researchers found that 17% of respondents who tested positive for the coronavirus reported a rash as the first symptom of the disease. For 21% of people who reported a rash and had confirmed Covid-19, the rash was their only symptom.

The researchers reported their findings in a pre-print study posted to the online server The findings have not been published yet in a peer-reviewed journal.

“Many viral infections can affect the skin, so it’s not surprising that we are seeing these rashes in Covid-19,” Dr. Veronique Bataille, consultant dermatologist at St Thomas’ Hospital and King’s College London, who was involved in the pre-print study, said in a press release in July.

“However, it is important that people know that in some cases, a rash may be the first or only symptom of the disease,” Bataille said. “So if you notice a new rash, you should take it seriously by self-isolating and getting tested as soon as possible.”

Measles-like rashes and rashes inside the mouth

Preliminary research has suggested that skin rashes and lesions inside the mouth might be a symptom of coronavirus infection — but researchers say more study is needed.

In May, scientists around the world did a literature review and found patients were also presenting with red, itchy welts, and with a red or pinkish rash that looked a lot like measles.

“It’s a reaction that we typically call morbilliform which means measles, which presents in kind of pink spots, lots of little pink spots all over the skin,” said Papier, the dermatologist at the University of Rochester Medical Center.

Another study published in JAMA Dermatology in July, found that among 21 patients in Spain who were confirmed to have Covid-19 and skin rash, six of those patients or 29% had enanthem, or lesions or rash in the mouth.

The mean amount of time between the onset of Covid-19 symptoms and developing enanthem was about 12 days among the patients, according to researchers from the Hospital Universitario Ramon y Cajal in Madrid.

“This work describes preliminary observations and is limited by the small number of cases and the absence of a control group,” the researchers wrote, adding that their findings still suggest enanthem to be a possible Covid-19 symptom and not a reaction to medications, for instance.

“Despite the increasing reports of skin rashes in patients with COVID-19, establishing an etiological diagnosis is challenging,” the researchers wrote. “However, the presence of enanthem is a strong clue that suggests a viral etiology rather than a drug reaction.”

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COVID-19: Cutaneous manifestations and issues related to dermatologic care

Authors: Steven R Feldman, MD, PhD, Esther E Freeman, MD, PhD Literature review current through: Jul 2021. | This topic last updated: Apr 06, 2021.


Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), raises many critical issues in dermatology and dermatologic care. Addressing these issues is necessary, yet also challenging, because there are few direct data on which to base recommendations [1].

This topic will discuss issues related to dermatologic care during the COVID-19 pandemic. Other relevant aspects of SARS-CoV-2 infection and patient management are discussed in detail separately.

●(See “COVID-19: Epidemiology, virology, and prevention”.)

●(See “COVID-19: Clinical features”.)

●(See “COVID-19: Diagnosis”.)

●(See “COVID-19: Infection control for persons with SARS-CoV-2 infection”.)

●(See “COVID-19: Outpatient evaluation and management of acute illness in adults”.)

●(See “COVID-19: Hypercoagulability”.)

●(See “COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis”.)

●(See “COVID-19: Management in hospitalized adults”.)

●(See “COVID-19: Questions and answers”.)

●(See “COVID-19: Cancer screening, diagnosis, post-treatment surveillance in uninfected patients during the pandemic, and issues related to COVID-19 vaccination in cancer patients”.)

●(See “COVID-19: Care of adult patients with systemic rheumatic disease”.)


Case series from around the world have identified a range of potential dermatologic manifestations of coronavirus disease 2019 (COVID-19) [2-5]. The frequency (ranging from 0.2 to 20.4 percent of cases) and timing of cutaneous manifestations of COVID-19 are difficult to ascertain [6-8]. Also unclear is the association of certain skin manifestations with the illness severity [9]. Moreover, it cannot be excluded that in some patients the observed skin findings may represent cutaneous reactions to the numerous treatments used for COVID-19 [9,10].

The American Academy of Dermatology’s COVID-19 Registry, a collaboration between the American Academy of Dermatology and the International League of Dermatologic Societies, is attempting to collate cases and better define the cutaneous manifestations of COVID-19 [11] (see ‘Registries’ below). Among 171 laboratory-confirmed COVID-19 patients with cutaneous manifestations from the registry, the most commonly reported were morbilliform rash (22 percent), pernio-like acral lesions (18 percent), urticaria (16 percent), macular erythema (13 percent), vesicular eruption (11 percent), papulosquamous eruption (9.9 percent), and retiform purpura (6.4 percent) [12]. Fever and cough were reported in approximately 60 percent of cases:

Exanthematous (morbilliform) rash – In several case series, a morbilliform rash predominantly involving the trunk has been reported as the most common cutaneous manifestation of COVID-19 [2,3,7,12-14]. The rash has been noted either at the disease onset or, more frequently, after hospital discharge or recovery [7].

Pernio (chilblain)-like acral lesions – Pernio (chilblain)-like lesions of acral surfaces (“COVID toes”) present as erythematous-violaceous or purpuric macules on fingers, elbows, toes, and the lateral aspect of the feet, with or without accompanying edema and pruritus (picture 1A-B). They have been described across the age spectrum in patients with confirmed or suspected COVID-19, in the absence of cold exposure or underlying conditions associated with pernio [2-4,12,15-22].

Resolution may occur in two to eight weeks. A prolonged course of more than 60 days has been reported in some patients with pernio (“long haulers”) [23].

The development of pernio-like lesions in COVID-19 may be associated with a relatively mild COVID-19 disease course [2,4,24]. In the American Academy of Dermatology/International League of Dermatologic Societies registry study, 55 percent of patients overall were otherwise asymptomatic. Ninety-eight percent of patients in the study were treated in the outpatient setting alone; this finding held true when restricted to laboratory-confirmed cases only, with 78 percent remaining in the outpatient setting [4].

Our understanding of the pathogenesis of these lesions is still under evolution, though it appears to be a primarily inflammatory process with histopathologic and direct immunofluorescence findings similar to those seen in idiopathic and autoimmune-related pernio [3,18,20,25-28]. (See “Pernio (chilblains)”.)

A French study demonstrated increased in vitro production of interferon-alpha from stimulated peripheral blood T cells in patients with pernio compared with patients with polymerase chain reaction (PCR)-positive, moderate to severe COVID-19 [29]. The histologic and biologic patterns of these patients with pernio were similar to a type I interferonopathy, suggesting that a robust, innate immune response may lead to rapid control of the virus in these patients and could, at least in part, explain the relatively mild disease course and low level of antibody production.

Pernio-like lesions may represent a postviral or delayed-onset process, with 80 out of 318 cases in the American Academy of Dermatology/International League of Dermatologic Societies registry developing lesions after the onset of other COVID-19 symptoms [4]. This finding is similar to data from Spain, where 42 out of 71 patients developed lesions after other symptoms [2].

There are several case reports and case series of patients with pernio-like lesions testing positive for immunoglobulin M (IgM), immunoglobulin G (IgG), or immunoglobulin A (IgA) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and negative for PCR, possibly indicating a later stage in the disease process [4,24,30]. However, pernio-like lesions can, in some cases, appear while patients are still PCR positive for the virus, which has potential implications for infectivity and viral spread [4,22]:

•In a French, prospective study, 40 consecutive patients with chilblain-like lesions (median age 22 years, range 12 to 67) were tested for SARS-CoV-2 RNA with reverse transcription (RT)-PCR and SARS-CoV-2-specific IgA, IgM, and IgG antibodies with enzyme-linked immunosorbent assays (ELISAs) [24]. None of these patients were PCR positive at the time of dermatologic consultation; 12 (30 percent) had positive serology for antibodies, of whom seven had only IgA. Twenty-five patients (63 percent) were asymptomatic, and the remaining had only mild symptoms.

•In another French series of 311 patients (median age 26 years) with acral manifestations seen between March and May 2020, 150 (49 with symptoms suspicious for COVID-19) underwent nasopharyngeal swab RT-PCR and/or serology for SARS-CoV-2 [31]. Five of 75 patients were positive for SARS-CoV-2 serology, and 7 of 121 patients were positive for SARS-CoV-2 RT-PCR. Overall, 10 of 170 patients (7 percent) had confirmed COVID-19.

•In the American Academy of Dermatology/International League of Dermatologic Societies registry study, of 318 cases from eight countries, 14 of these cases were PCR positive.

•In an Italian study that screened 22 patients presenting with pernio-like lesions, 6 (26 percent) were PCR positive for SARS-CoV-2 [22].

Although the finding of PCR positivity is not universal and not all observed cases of pernio during the COVID-19 epidemic are necessarily related to COVID-19, it may be prudent that patients presenting with new-onset, pernio-like lesions that have no other clear cause be tested for SARS-CoV-2 PCR within seven days of the onset of pernio lesions [32-35]. For patients who have had these lesions for >4 weeks, IgM and IgG antibody testing may be appropriate, following local guidelines and depending on the quality of available tests, acknowledging that many of these patients may only make transient antibody responses or IgA responses that are not currently being tested in commercial laboratories. Work-up of other causes of pernio is discussed in greater detail separately [2,4,24]. (See “Pernio (chilblains)”.)

There are no treatment guidelines for COVID-19-associated, pernio-like lesions of the feet or hands. However, high-potency topical corticosteroids may be helpful if the lesions are causing discomfort.

Some patients have been noted to have “long COVID”/long-hauler COVID toes [23]. Additionally, some patients have been found to have recurrent pernio after initial SARS-CoV-2 infection, which may be triggered by cold [36].

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Skin rash should be considered as a fourth key sign of COVID-19

May 22, 2021

Data from the COVID Symptom Study shows that characteristic skin rashes and ‘COVID fingers and toes’ should be considered as key diagnostic signs of the disease, and can occur in the absence of any other symptoms. 

The COVID Symptom Study, led by researchers from King’s College London and health science company ZOE, asks participants to log their health and any new potential symptoms of COVID-19 on a daily basis. After noticing that a number of participants were reporting unusual skin rashes, the researchers focused on data from around 336,000 regular UK app users. 

Researchers discovered that 8.8% of people reporting a positive coronavirus swab test had experienced a skin rash as part of their symptoms, compared with 5.4% of people with a negative test result. Similar results were seen in a further 8.2% of users with a rash who did not have a coronavirus test, but still reported classic COVID-19 symptoms, such as cough, fever or anosmia (loss of smell).

To investigate further, the team set up a separate online survey, gathering images and information from nearly 12,000 people with skin rashes and suspected or confirmed COVID-19. The team particularly sought images from people of colour, who are currently under-represented in dermatology resources. Thank you to all who submitted photographs of their rashes.

17% of respondents testing positive for coronavirus reported a rash as the first symptom of the disease. And for one in five people (21%) who reported a rash and were confirmed as being infected with coronavirus, the rash was their only symptom.

The rashes associated with COVID-19 fall into three categories: 

  • Hive-type rash (urticaria): 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.
  • ‘Prickly heat’ or chickenpox-type rash (erythemato-papular or erythemato-vesicular 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.
  • COVID fingers and toes (chilblains): Reddish and purplish bumps on the fingers or toes, which may be sore but not usually itchy. This type of rash is most specific to COVID-19, is more common in younger people with the disease, and tends to present later on.

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