Enduring skin symptoms in COVID ‘long-haulers’

By Mardi Chapman

4 Nov 2020

Dr Esther Freeman

There is an underrecognised subset of patients with COVID-19 experiencing dermatological symptoms beyond 60 days.

Speaking at the virtual EADV 29th Congress, Dr Esther Freeman said these “long-haulers” with dermatological manifestations of COVID-19 were of interest for clues to the underlying pathophysiology or large-scale inflammation in the body.

Dr Freeman, principal investigator in the international Dermatology COVID-19 Registry, presented data on dermatology symptom duration from 224 COVID-19 cases, 90 of which were laboratory confirmed.

She said the data showed that urticaria was relatively short lived – a median of five days in all cases and four days in the laboratory confirmed sub-group.

In contrast, papulosquamous symptoms lasted a median 20 days across all cases and in the lab confirmed cases.

Morbilliform symptoms lasted about a week (7 days for both all cases and lab confirmed), macular erythema 10 and 7 days respectively, vesicular symptoms 12 and 10 days, pernio/chilblains 15 and 10 days, and retiform purpura 20 and 17 days.

“We need to be reassuring to most of our patients that develop pernio in the setting of COVID. Most of the patients we are seeing, both in the registry and in my own personal cohort of patients I am taking care of, do have their symptoms resolve. The median duration in the registry was 15 days. And in most of the patients the pain and discomfort only last about a week.”

However Dr Freeman said there were outliers. For example, six patients were reported to have pernio for 60 days or longer.

“I think it is important to note the registry data likely underrepresents the reality because most of the providers did data entry at one time period very shortly after seeing the patient and if the symptoms were ongoing, the full course may not have been captured,” she said.

“Nine months after the onset of COVID-19 pandemic, there is increasing appreciation for persistent morbidity beyond the acute phase of the disease,” she concluded.

She said there was not yet enough data to comment on any correlation between the duration of dermatological symptoms and other symptoms such as neurologic and cardiac COVID-19 symptoms.

However other registry data had shown a link between the type of dermatological manifestation and severity of COVID-19 disease.

For example, in patients presenting with pernio/chilblains, otherwise known as COVID toes, only 16% were hospitalised. However 100% of patients with retiform purpura, which likely signified underlying clotting, were hospitalised.

About 22-45% of patients with vesicular, urticarial, macular erythema, morbilliform symptoms were hospitalized.

Dr Freeman, who is also a member of the AAD Task Force on COVID-19, Assistant Professor of Dermatology at Harvard Medical School, and Director of Global Health Dermatology at Massachusetts General Hospital, said the registry now has more than 1,000 cases from 41 countries.

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