COVID-19 and dermatology patients

Please note that DermNet’s page is a summary about COVID-19 and may quickly become outdated.

See COVID-19 images.

Refer to Government websites for up-to-date information about COVID-19.

• World Health Organization (WHO)
• United States of America Centers for Disease Control (CDC)
• United Kingdom Government
• United Kingdom National Health Service
• Australian Government
• New Zealand Government Unite against COVID-19
• New Zealand Ministry of Health

CDC*

New Zealand Government^

*Credit: CDC COVID-19 website
^Credit: New Zealand Government Unite against COVID-19 website

What is COVID-19?

COVID-19 (coronavirus disease 2019) is an illness that may lead to serious respiratory disease and may be fatal. It is caused by the virus SARS-CoV-2. The first human cases occurred in China in December 2019, and the infection rapidly spread throughout the world.

• SARS-CoV-2 belongs to the same family as SARS-CoV, the coronavirus that caused the outbreak of lethal SARS (severe acute respiratory syndrome) in 2003 [1].
• COVID-19 and SARS are different diseases.
• Other coronaviruses cause the common cold, pharyngitis, laryngitis, and 'flu-like symptoms.
• The cell receptor for SARS-CoV-2 is the angiotensin-converting enzyme (ACE)-2 in the respiratory system.

The World Health Organisation declared on 11 March 2020 that the COVID-19 outbreak was an official pandemic, as COVID-19 had spread rapidly worldwide.

There is currently no known vaccine or cure (March 2020).

Transmission electron micrograph of a SARS-CoV-2 virus particle, isolated from a patient. Image captured and color-enhanced at the NIAID Integrated Research Facility (IRF) in Fort Detrick, Maryland.

This scanning electron microscope image shows SARS-CoV-2 (round gold objects) emerging from the surface of cells cultured in the lab. SARS-CoV-2, also known as 2019-nCoV, is the virus that causes COVID-19. The virus shown was isolated from a patient in the U.S.

Transmission electron micrograph of SARS-CoV-2 virus particles, isolated from a patient. Image captured and color-enhanced at the NIAID Integrated Research Facility (IRF) in Fort Detrick, Maryland.

For more images of the SARS-CoV-2 virus, see the National Institute of Health's COVID-19 image gallery.

Who gets COVID-19?

COVID-19 affects people of all ages. Older persons, those with underlying chronic medical conditions, and those who are immunosuppressed have a higher risk of developing severe, life-threatening illness [1]. However, young and otherwise healthy people can also become very sick and may die.

The most common underlying chronic medical conditions that are reported to result in more severe disease include:

• Diabetes
• Cardiovascular disease including hypertension
• Chronic obstructive pulmonary disease.

How is COVID-19 spread?

The SARS-CoV-2 virus is found in droplets spread by an infected individual that has been coughing, sneezing, talking, or touching items. The droplets may land on surfaces such as door handles, computer keyboards, and table-tops. The virus remains infectious for several days on smooth surfaces but shorter periods on paper, wood, or cloth [2].

An uninfected individual may touch such an invisible droplet then touch their face, transmitting the virus through the mucous membranes of their mouth, nose, and eyes, resulting in infection.

The incubation period before the infection is 2–10 days in most people.

Patients are infectious for a couple of days before becoming unwell, when unwell, and for some time after clinical recovery.

Infected people without symptoms are also infectious. Although their rate of spreading the infection is about 55% of those with symptoms, worldwide, this group is thought to contribute to the spread of the virus tenfold. In countries where there is evidence of community spread, extreme physical restrictions are required to prevent a logarithmic increase in cases.

What are the symptoms of COVID-19?

The severity of COVID-19 is variable. Some people infected with the virus SARS-CoV-2 do not develop any symptoms. The most common symptoms of COVID-19 are:

• Fever
• Dry cough
• Shortness of breath
• Loss of smell and taste
• Fatigue/tiredness.

Less common symptoms include:

• Body aches and pains
• Runny or blocked nose
• Sore throat
• Abdominal pain
• Diarrhoea
• Headache
• A heightened clotting tendency
• Kidney disease
• Cardiomyopathy
• A Kawasaki disease-like presentation in children termed paediatric inflammatory multisystem syndrome [3]
• Neurological symptoms such as confusion and coma
• And many more.

People with these symptoms, and those who have been in close contact with them, should not go to work and should strictly self-isolate, following local guidelines. Those with serious symptoms may need hospitalisation and mechanical ventilation due to viral pneumonia.

Cutaneous signs of COVID-10

Skin rashes have been uncommonly described in patients with COVID-19. Descriptions include:

• An erythematous exanthem (including a lacy pattern and a petechial, dengue-like rash)
• Livedo reticularis
• Cutaneous vasculitis
• Acute urticaria
• Chickenpox-like blisters [4]
• 'COVID toes', in which there are digital infarcts resulting in black crusted lesions on the tips of fingers and toes, which are described as like pernio/chilblains or frostbite.

Exanthem associated with COVID-19

Rash associated with COVID-19

Rash on feet associated with COVID-19

Suspected COVID-19 rash

Postinflammatory hypopigmentation and desquamation can follow as the rash resolves.

Postinflammatory hypopigmentation after recovery from dengue-like rash in a patient with suspected COVID19.

Postinflammatory hypopigmentation after recovery from dengue-like rash in a patient with suspected COVID19.

Postinflammatory desquamation on the foot of a patient with suspected COVID-19 infection

See more COVID-19 images.

How is COVID-19 diagnosed?

COVID-19 is diagnosed using respiratory swabs. These real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) tests detect the SARS-CoV-2 virus. Tests for other respiratory infections such as influenza and respiratory syncytial virus (RSV) may be done at the same time.

• A positive result means the patient has active COVID-19 (or one of the other infections tested).
• A negative swab is not reliable — the patient may still have COVID-19.
• The test may be repeated if symptoms progress or for public health purposes.
• The test may not be offered to everyone requesting it.

Antibody blood tests to test whether someone has previously been exposed to SARS-CoV-2 and have mounted an immune response are not yet available in New Zealand.

The diagnosis of COVID-19 may also be made clinically where the patient has been in contact with a COVID-19 patient, where community infection is widespread, or the patient has recently travelled from a country with community infection.

Other tests will depend on the symptoms and signs of an infected patient. For example, patients with COVID toes should be investigated with CBC, d-dimers, fibrinogen, ANA, and a coagulation panel.

An electron microscope image showing particles of the new coronavirus being released from an infected cell.

This transmission electron microscope image shows SARS-CoV-2, the virus that causes COVID-19, isolated from a patient in the U.S. Virus particles are shown emerging from the surface of cells cultured in the lab. The spikes on the outer edge of the virus particles give coronaviruses their name, crown-like.

This transmission electron microscope image shows SARS-CoV-2—also known as 2019-nCoV, the virus that causes COVID-19—isolated from a patient in the U.S. Virus particles are shown emerging from the surface of cells cultured in the lab. The spikes on the outer edge of the virus particles give coronaviruses their name, crown-like.

Note: Electron microscopy is not used as a standard test to identify SARS-CoV-2.

What is the treatment for COVID-19?

Treatment of COVID-19 depends on the specific features of an individual's presentation. Patients with difficulty breathing or other serious symptoms should be assessed by a doctor and may be hospitalised.

How can COVID-19 be prevented?

COVID-19 can be prevented — this is why many countries have enforced a ‘lockdown’ and are requiring people to stay at home.

The following personal health practices are strongly encouraged to reduce the risk of infection.

Physical distancing

Keeping a minimum distance between yourself and others to prevent physical contact and possible contamination is an essential step in preventing the spread of the virus.

• Stay at home; do not go out unless absolutely necessary (this can include visiting a supermarket or pharmacy, or physical exercise limited to your neighbourhood; follow your local guidelines).
• Avoid being closer than 2 metres from others [5].
• Greet people by waving instead of shaking hands.
• Keep in touch with family and friends remotely by phone or via the Internet.

Frequent handwashing

Handwashing is the most effective way to prevent infection.

• Wash your hands frequently with soap and water [6].
• Alternatively, use a hand sanitiser with an alcohol content of at least 60%.
• Scrub the backs of both hands, between the fingers, and under the nails for at least 20 seconds. If you have sensitive skin, rinse off thoroughly.
• Dry your hands with a clean cloth or dry paper towels.
• Moisturisers do not kill SARS-CoV-2 virus so you will still need to wash with soap and water or a moisturising sanitiser if you have previously been given a moisturiser as a soap substitute.
• Use an oil-based moisturiser such as petroleum jelly to moisturise the hands, preferably about 30 minutes after washing. This will protect the skin from hand dermatitis due to over-washing (see compulsive hand washing). Moisturising your hands will not affect the cleansing properties of handwashing.
• Do not touch your eyes, nose, or mouth unless your hands are clean.

Good hygiene etiquette

Practice these hygiene measures to prevent the spread of the virus through droplets or physical contact.

• Cough and sneeze into your inner upper arm to prevent your hands from becoming dirty and spreading an infection to other people or surfaces [7].
• If tissues are used, throw them away immediately and wash your hands properly.
• Wipe down surfaces using bleach or antiseptic product.
• Don’t share food and drink, toothbrushes, clothing, bedding, or towels.
• If involved in healthcare for patients with COVID-19, wear properly applied personal protective equipment after a thorough training in its use.

Should my skin medications be continued?

Commonly used systemic medications for severe skin conditions include immunomodulators or immunosuppressive drugs. These may include a biological agent, a disease-modifying anti-rheumatic drug (DMARD), or a systemic steroid. Dermatological medications are not known to increase the risk of acquiring COVID-19.

If you are currently well, and do not have any other chronic medical conditions [8,9]:

• Continue taking your medications as prescribed
• Remember that these medications were started to treat a severe, long-term medical condition
• The skin condition is very likely to deteriorate if the systemic medication is stopped suddenly.

If you have tested positive for SARS-CoV-2:

• Inform your doctor about your skin condition and the medications you are currently taking
• Oral retinoids such as acitretin and isotretinoin can be continued as prescribed [9]
• If you are taking an immune-suppressive medication, such as ciclosporin, mycophenolate, or azathioprine, or if you are not sure, ask your doctor if you should reduce the dose or stop it
• If you are taking methotrexate or a biologic agent, the dose should be reduced, or the medication stopped for at least four weeks or until you have fully recovered from COVID-19 [8]
• Systemic corticosteroids should not be abruptly discontinued but slowly weaned as advised by your doctor [9].

If you have cold or flu-like symptoms [9]:

• Local guidelines may apply; ask your doctor
• A dose reduction or treatment interruption for two weeks may be considered if you are on an immunomodulator
• Systemic steroids should be continued; ask your doctor if you should stay on the same dose, increase it, or reduce the dose.

The influenza vaccine by intramuscular injection is highly recommended for all patients without contraindications [9]. See immunisation in immunosuppressed dermatology patients.

What is the outlook for patients with COVID-19?

Although most people with COVID-19 completely recover within one to three weeks, some have described variable and often debilitating symptoms for months after contracting the infection. The range of disorders is under active investigation.

Mortality is greatest in older people, especially those over 70 years, and with immune suppression. For example, one-in-four cardiac transplantation patients infected with COVID-19 died from the infection [10].

For current statistics, see the WHO's situation reports.

As of 18 May 2020, COVID-19 infection was officially reported for 4,618,821 patients with 311,847 deaths. On 18 May, there were 1,499 confirmed and probable cases in New Zealand with 21 deaths.

For more information

In New Zealand, refer to:

• The Government website, https://covid19.govt.nz.
• Wang C, Rademaker M, Baker C, Foley P. COVID-19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: An Australia/New Zealand consensus statement. Australas J Dermatol. 2020 Apr 7. doi: 10.1111/ajd.13313. Epub ahead of print. PMID: 32255510.