Initially, reported symptoms of the novel SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), responsible for the coronavirus disease 2019 (COVID-19), were limited to upper respiratory tract symptoms, such as coughing, fever, and shortness of breath. Since then, other emerging case reports and clinical studies suggest the virus may be associated with ocular symptoms,1,2 gastrointestinal symptoms,3 loss of taste and/or smell,4 and dermatologic manifestations as well.
An early study published online in March reported only 1 patient with a rash in Germany; however, the connection to the virus in this patient was not clear.5 A study from Italy showed 18 patients had skin symptoms, including erythematous rash, widespread urticaria, and chickenpox-like vesicles.6 A case report from Thailand showed a patient with petechia was misdiagnosed with dengue but was later found to have COVID-19.7 Recently, a new symptom dubbed the “COVID toes” is being reported by physicians, across social media, and in news media outlets Business Insider and Today.com.8,9
In response to the increased number of health care providers noting possible skin signs on patients with suspected or confirmed COVID-19, the American Academy of Dermatology (AAD) has created a registry for collecting data on possible skin manifestations related to the virus.10
Esther Freeman, MD, PhD, principle investigator for the COVID-19 Dermatology Registry, built in collaboration with the American Academy of Dermatology and the International League of Dermatologic Societies (ILDS), discussed the registry in an interview with The Dermatologist. Dr Freeman is a member of the AAD Ad Hoc Taskforce for COVID-19 and Director of Global Health Dermatology at Massachusetts General Hospital and Harvard Medical School.
The Dermatologist: Why did the AAD create this registry, and could you tell us a little more about it?
Dr Freeman: We created the registry in order to capture dermatologic manifestations of COVID‑19. We are collaborating with the ILDS in order to truly make this an international registry. Importantly, this is not just for dermatologists or members of the AAD, but for any health care provider who is seeing patients with COVID-19 that might have a possible skin symptom.
In this registry, we are trying to capture as much data as possible on the interplay between the skin and COVID-19. There are a number of different groups of patients that we are including in the registry: first, patients with COVID‑19, either confirmed or suspected, who go on to develop skin manifestations that might be related to the virus. The second group of patients are those who have pre‑existing dermatologic conditions that might be potentially affected by COVID‑19. Finally, the third group comprises patients who are on dermatologic medications who might go on to develop COVID‑19.
The registry has gone through ethical review and was deemed “not human subjects research.” No protected health information is requested, and only de-identified patient data is entered. We are not collecting any identifiable information on the cases submitted in the registry.
The Dermatologist: What are the steps for who is completing the survey for interested providers, and so far, who has been completing it?
Dr Freeman: We are encouraging health care providers from any specialty to enter information into our database so that we can have representation across different fields on skin findings potentially related to COVID-19. I’m pleased to say we do have providers from many different fields currently entering information.
Entering a case takes about 5 to 7 minutes. In terms of the type of information, we are collecting information around a patient’s COVID-19 case such as, was this confirmed or suspected, if they had any lab testing and, if so, what kind, treatment they may have received, and details on their disease course. For example, if they developed a dermatologic manifestation of COVID-19, such as a new rash or pernio‑like lesions of the feet, we might ask for some more details around the timing of the disease course or some description of the lesion.
Our first priority is to capture cases that are confirmed COVID-19 cases, either PCR or antibody‑tested positive for COVID‑19. That being said, we understand that right now there is incomplete testing and not everyone who potentially needs or is eligible for a test is able to receive one. That is why we are collecting cases where a provider may suspect that the patient has COVID-19.
The Dermatologist: What are some of the skin findings being reported in the registry? And, what should providers, especially those on the frontlines of treating this disease, keep in mind in regard to potential skin manifestations?
Dr Freeman: One of the most notable reported skin signs, and most talked about, are the pernio-like lesions of the feet, which have been dubbed ‘COVID toes’ by the dermatology community. The lesions look similar to those that can be caused by pernio/chilblains, which are red and purple lesions caused by a cold-induced skin injury [Same here]. They can occur on the fingers as well as the toes. We are seeing a surprising amount of reports of patients with ‘COVID toes,’ though we are not sure if all of them are truly associated with the virus. We are seeing reports of these findings in patients with PCR confirmed disease, but we also have a lot of reports from patients who were not able to get tested for COVID.
The other cases reported in the registry include a variety of rashes, including morbilliform rashes (nonspecific viral rashes that can resemble measles). There have also been reports of urticaria (hives), and varicella-like eruptions, among many others.
I encourage our infectious disease, internal medicine, primary care colleagues to keep a look out for possible skin manifestations of COVID-19, and to please report those cases in the registry.
As dermatologists, I don’t think that we are surprised that there are skin manifestations of COVID-19, because we see a lot of rashes with other viruses. The pernio-like lesions of the feet have been more surprising to me, personally, because they are not as frequently seen with other viruses.
The Dermatologist: Could you explain how you intend to analyze the data of the registry and its limitations?
Dr Freeman: We are performing real-time data analysis of the registry data, in our attempt to feed data back to front line providers as quickly as possible. Some of our results are under review at a medical journal at this time. I will note that we stratify our analysis based on the type of COVID-19 testing a patient has – so we do not mix confirmed cases with suspected cases.
The registry has limitations. It is not an epidemiologic cohort or case control study. We cannot give a population-based incidence or prevalence of these skin findings in COVID-19. And, perhaps most importantly, we cannot assign causation.
I like to refer to registries as hypothesis-generating, which means they can generate a lot of questions and can capture unique cases from around the world. However, there is still a lot of research that will need to be done. You can look at the registry as a crucial first step.
The Dermatologist: What are the next steps?
Dr Freeman: Next steps would be to get a clear understanding of who actively has COVID-19, or who has had COVID-19 in the past. Without improved rollout of both PCR and high-quality antibody testing, it is going to be very challenging to answer questions around dermatologic manifestations of COVID-19 more definitively. Increasing testing is a critical step in order to perform larger-scale studies.
The Dermatologist: Are there any other thoughts or comments about the registry you would like to leave with our audience?
Dr Freeman: Collaboration is key to this registry. First, I would like to thank the international community. Dermatologists, through social media platforms and emails, have been getting in touch with us to share cases, and encouraging colleagues to enter cases. It is really a big team effort, involving too many people to name here, and we are so appreciative of everyone contributing to the registry.
Secondly, I think this is a testament to international collaboration and the health care community being willing to work together at a very rapid pace during these unique times. For me, the international collaboration around this has been a bright spot in an otherwise dark time. For example, prior to the pandemic, I estimate that getting a registry like this off the ground would take about 6 months. We were able to go from the idea of the registry, to it going through ethical approval and going live, to collecting our first patient data in 8 days.
That was due to buy‑in from the AAD leadership, the AAD ad hoc task force on COVID‑19, AAD staff, and also from the International League of Dermatologic Societies. This took a lot of people pulling together to make this happen so quickly. Time is really of the essence now as we are trying to understand what is going on and feed this information back to our frontline health care providers.
The Dermatologist: Are there any other resources from the AAD that you would like to highlight for dermatologists?
Dr Freeman: In addition to our registry, I encourage dermatologists to visit our COVID‑19 resource center on the AAD website. The AAD COVID‑19 task force, along with AAD staff, has been keeping it up-to-date with the latest information and has really developed a large library that includes interim guidelines on medications, guidance on telemedicine, and governmental regulations, among others. The newest section offers interim practical guidance for considerations when reopening a practice, when the time comes.
I am proud of the work we have done on the AAD COVID-19 Task Force. I want to extend my heartfelt thanks to dermatologists across the country who have reached out to the task force with particular questions or issues they thought we should address, and to all of those across the medical community who have entered cases into the registry.
For more information about the registry and submit a case, please visit: www.aad.org/covidregistry.
1. Chen L, Liu M, Zhang Z, et al. Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease [published online April 7, 2020]. Br J Ophthalmol. doi:10.1136/bjophthalmol-2020-316304
2. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China [published online March 31, 2020]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2020.1291
3. Pan L, Mu M, Yang P, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: A descriptive, cross-sectional multicenter study [published online March 18, 2020]. Am J Gastroenterol. https://journals.lww.com/ajg/Documents/COVID_Digestive_Symptoms_AJG_Preproof.pdf
4. Yan CH, Faraji F, Prajapati DP, Boone CE, DeConde AS. Association of chemosensory dysfunction and Covid-19 in patients presenting with influenza-like symptoms [published online April 12, 2020]. Int Forum Allergy Rhinol. doi:10.1002/alr.22579
5. Hoel S, Rabenau H, Berger, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China [published online February 18, 2020]. N Engl J Med. doi:10.1056/NEJMc2001899
6. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [published online March 26, 2020]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16387
7. Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol. 2020;82(5):e177. doi:10.1016/j.jaad.2020.03.036
8. Lee YJ. 'COVID toes' might be the latest unusual sign that people are infected with the novel coronavirus. Business Insider. https://www.businessinsider.com/covid-toes-frostbite-coronavirus-skin-lesion-discolored-swollen-feet-2020-4. Published April 23, 2020. Accessed April 28, 2020.
9. Hohnman M. What are COVID toes? Today.com. https://www.today.com/health/skin-symptoms-related-coronavirus-doctors-discuss-covid-toes-t178991. Published April 17, 2020. Accessed April 28, 2020.
10. Freeman EE, McMahon DE, Fitzgerald ME, et al. The AAD COVID-19 Registry: Crowdsourcing sermatology in the age of COVID-19 [published online April 16, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.04.045