Why are skin changes an important part of the clinical picture of corona virus infection?
The virus responsible for COVID-19 can lead to changes in the skin. Are these changes common or specific to this disease, and how frequently do they occur? We discuss this with Dr. Jasmina Kozarev, a dermatologist.
After months of battling the virus, we now know that its tropism affects bronchial mucosa structures and immune response cells, leading to inflammatory changes in the heart, blood vessels, liver, and kidneys, but not the typical skin changes. Mucous membranes have been identified as the most common entry points for infection, including conjunctiva and even the ear canal, which has the lowest risk of transmission. However, damaged skin surfaces can also represent possible entry points for the virus.
Therefore, specific and characteristic skin changes due to COVID-19 infection have not been described, but nonspecific and secondary skin changes related to certain medications necessary for treating COVID-19 infection can be expected.
It is essential to know that a damaged epidermal barrier allows the virus to be transmitted indirectly, so some patients with chronic dermatoses may be considered at increased risk for transmission. COVID-19 has relatively low resistance to disinfectants. Consequently, various disinfection procedures have proven effective, ranging from 75% ethanol, hydrogen peroxide, chlorine, and UV radiation to washing in warm water at 56 °C for 30 minutes. All these procedures allow the virus to be rinsed off from objects and clothing. However, treating skin with peroxide and alcoholic solutions also removes the skin's natural protective barrier.
Practical care for patients with autoimmune and chronic inflammatory skin diseases, such as psoriasis, atopic dermatitis, lupus, scleroderma, hidradenitis, and any conditions requiring immunosuppressive therapy, is also crucial. There is currently no consensus on whether to postpone the use of biological medications.
Skin Changes Due to Blood Vessel Alterations
Increased blood clotting is one of the severe complications arising from SARS-CoV-2 infection, suggesting it is a systemic disease. The coronavirus raises the risk of blood clotting, leading to cardiovascular problems and organ failure in some patients, particularly those with preexisting conditions such as diabetes, obesity, or hypertension.
Blood clots increase the risk of deep vein thrombosis, heart attack, or stroke. Other systemic changes associate COVID-19 with neurological issues, painful red and swollen areas on the skin of the legs (referred to as "COVID toes"), or other skin rashes. Intravascular coagulation appears to be a distinctive feature of this disease.
Platelets are crucial cellular components involved in the blood clotting mechanism. COVID-19 has been found to alter platelet characteristics, leading to their aggregation within blood vessels, narrowing and closing the lumen, resulting in heart attacks, strokes, and other severe complications. Dr. Jasmina Kozarev notes that studies have shown that coronavirus infection can create hormonal imbalances, leading to increased thrombosis, especially in young individuals. There is also evidence indicating damage to blood vessel walls in patients with COVID-19 infection, including those without stroke symptoms or thrombosis.
It is important to understand that viral infections and inflammatory diseases always increase the risk of thrombosis.
Skin Problems as Part of the Clinical Picture of COVID-19
Dr. Jasmina Kozarev describes that in some patients, diffuse maculopapular rashes resembling smallpox, urticaria-like rashes, or rashes resembling chickenpox in COVID-19 positive patients are integral to the clinical picture of the disease. In severe cases of the disease, besides changes in the fingers manifested as erythematous ischemic areas, reticular livedo changes and gangrenous changes may also be observed.
Thus, skin changes should never be neglected. With the existing and ever-present fear that a rash will spread and lead to a general deterioration of health, in some cases, the appearance of a rash precedes typical respiratory infection symptoms such as cough, nasal congestion, runny nose, headache, and fever.
-
Urticaria (COVID-19 positive)
2. Measles similar to varicella (COVID-19 positive)
3. Morbilliform measles (COVID-19 positive)
Skin Problems Related to Personal Protective Equipment and Hygiene Measures
The first observed skin complications associated with COVID-19 infection were initially noted among healthcare personnel. These complications resulted from excessive moisture on the skin surface due to the side effects of using personal protective equipment, friction, degradation of the epidermal barrier, and contact reactions, all of which could exacerbate pre-existing skin conditions.
Dermatological manifestations such as erythema, papules, maceration, and increased desquamation were the most commonly reported skin changes due to prolonged mask usage. One study indicated that more than a third of healthcare workers complained of acne, facial itching, and even dermatitis from wearing masks.
Long-term use of protective gloves leads to occlusion and hyperhydration of the epidermis, which can clinically present as maceration and erosion, dyshidrotic eczema, and the development of contact dermatitis. Excessive handwashing with detergents and disinfectants can damage the skin's hydrolipid layer, leading to irritation and even contact dermatitis. Statistics show that two-thirds of healthcare workers wash their hands at least 10 times a day, yet only one-fifth of them use a protective skin cream to restore their skin's barrier.
One can only imagine the state of the general population regarding the inadequate use of protective creams among professionals.
Therefore, to prevent contact dermatitis, we recommend the use of DK protective hand cream 24/7, especially after handwashing and before putting on protective gloves. This product is paraben-free and preserved with peracetic acid, providing additional mild disinfectant properties.
Skin Problems as Part of the Clinical Picture of COVID-19
Dr. Jasmina Kozarev explains that some patients exhibit diffuse maculopapular rashes similar to smallpox, urticaria-like rashes, or rashes resembling those seen in chickenpox, all of which are observed in COVID-19 positive patients and are integral to the clinical picture of the disease. In more severe cases, in addition to changes in the fingers characterized by erythematous ischemic zones (commonly referred to as "COVID toes"), changes such as reticular livedo and gangrenous alterations may also be visible.
These new findings and scientific studies highlight the need to recognize skin rashes as an important symptom for the early identification of new and potentially predictive cases of COVID-19. This awareness allows for appropriate and timely treatment for all patients in the early stages of the illness.