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CME / ABIM MOC / CE

Do Skin Manifestations of COVID-19 Differ by Variant Type?

  • Authors: MDEdge News Author: Ted Bosworth; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 9/9/2022
  • Valid for credit through: 9/9/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care providers, dermatologists, infectious disease specialists, nurses, nurse practitioners, physician assistants, and other clinicians who care for patients at risk for COVID-19.

The goal of this activity is that learners will be better able to assess how cutaneous manifestations of COVID-19 have changed during the Delta and Omicron surges.

Upon completion of this activity, participants will:

  • Analyze common cutaneous manifestations of COVID-19
  • Assess how cutaneous manifestations of COVID-19 have changed during the Delta and Omicron surges
  • Outline implications for the healthcare team


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MDEdge News Author

  • Ted Bosworth

    Disclosures

    Ted Bosworth has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer:

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Do Skin Manifestations of COVID-19 Differ by Variant Type?

Authors: MDEdge News Author: Ted Bosworth; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/9/2022

Valid for credit through: 9/9/2023

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Most clinicians do not think of cutaneous symptoms as part of the spectrum of symptoms of COVID-19, and it is true that most patients with COVID-19 do not develop skin symptoms or signs; however, a review by Daneshgaran and colleagues, which was published in the October 2020 issue of American Journal of Clinical Dermatology,[1] found that cutaneous symptoms among patients with COVID-19 were not common and followed a wide range of patterns.

The most frequent lesion identified was acral sores or blisters of the toes ("COVID toes"), occurring among 40.4% of patients with skin symptoms. The mean age of patients with these symptoms was 23.2 years. Erythematous maculopapular rash affected 21.3% of patients, who had an average age of 53.2 years. Vesicular rashes affected 13% of patients, who also were generally middle-aged. Vascular rashes comprised 4% of the sample of patients, and these rashes occurred among older adults. Eruptions resembling erythema multiforme were found in 3.7% of patients and occurred primarily among children. Another important finding of this study is that cutaneous manifestations of COVID-19 generally began when other symptoms were already present.

Nonetheless, the typical symptoms of COVID-19 have shifted as new variants have swept across the globe. The current study by Visconti and colleagues updates cutaneous findings during the Delta and Omicron surges of COVID-19.

Study Synopsis and Perspective

Skin symptoms, such as systemic symptoms, differ by COVID-19 variant, according to a large retrospective study that compared clinical data from more than 300,000 participants in the United Kingdom during the Omicron and Delta waves.

Among the key findings, the study, published online July 22 in the British Journal of Dermatology,[2] showed that skin involvement during the Omicron wave was less frequent than during the Delta wave (11.4% vs 17.6%), skin symptoms generally resolved more quickly, and that the risk for skin symptoms was similar whether patients had or had not been vaccinated, according to a team led by Alessia Visconti, PhD, a research fellow in the department of twin research and genetic epidemiology, King's College, London, United Kingdom.

These data are consistent with the experience of those dermatologists who have been following this area closely, according to Esther Freeman, MD, PhD, associate professor of dermatology at Harvard Medical School and director of MGH Global Health Dermatology at Massachusetts General Hospital, both in Boston, Massachusetts.

"Anecdotally, we thought we were seeing fewer skin symptoms with Omicron versus Delta and the ancestral strains, and now this study shows it is true," said Freeman, who is also principal investigator of the American Academy of Dermatology's International Dermatology COVID-19 Registry.[3]

The data also confirm that the skin is less likely to be involved than in past waves of SARS-CoV-2 infections.

"Up to this point, it was hard to know if we were seeing fewer referrals for COVID-related skin rashes or if clinicians had just become more comfortable with these rashes and were not referring them as often," added Freeman, who was among the study coauthors.

Data Captured From 348,691 Patients

The data from the study was generated by 348,691 users in the United Kingdom of the ZOE COVID study app, a smartphone-based tool introduced relatively early in the pandemic. It asked users to provide demographic data, information on COVID-19 symptoms, including those involving the skin, and treatments. Of 33 COVID-related symptoms included in the app, 5 related to the skin (acral rash, burning rash, erythematopapular rash, urticarial rash, and unusual hair loss).

Although the focus of this study was to compare skin manifestations during the Omicron wave with the Delta wave of COVID-19, the investigators also had data on the experience in 2020 with wild-type COVID-19 that preceded both variants. Overall, this showed a stepwise decline in skin symptoms overall, as well in as skin symptoms that occurred in the absence of systemic symptoms.

"The shift in the skin manifestations makes sense when you think about the change that is also being seen in the systemic symptoms," said Freeman, referring to lower rates of cough and loss of smell but higher rates of sore throat and fatigue.

"Omicron is achieving immune escape, which is why there is a shift in involved tissues," she said in an interview.

Previous data[4] collected during the wild-type COVID-19 stage of the pandemic by the same group of investigators showed that 17% of patients reported skin rash as the first symptom of COVID-19 infection, and 21% reported skin rash as the only clinical sign of infection.

During the early stages of wild-type COVID, an acral rash was characteristic, occurring in 3.1% of patients, according to the UK data. In the Delta wave, acral rashes, at an incidence of 1.1% remained positively correlated with a diagnosis of COVID-19. In the Omicron wave, acral rashes were observed in only 0.7% of patients and were no longer statistically correlated with a positive COVID-19 diagnosis.

Characteristic Cutaneous Symptoms Are Evolving

Early in the course of the COVID-19 epidemic, more than 30 types of rashes were observed in patients with COVID-19. Cutaneous symptoms continue to be diverse, but some, such as acral rash, are being seen less frequently. For example, the odds ratio of a positive COVID-19 diagnosis among persons with an erythematopapular rash fell from 1.76 to 1.08 between the Delta and Omicron waves.

Although specific cutaneous symptoms are less predictive of a diagnosis of COVID-19, clinicians should not discount cutaneous symptoms as a sign of disease, according to Veronique Bataille, MD, PhD, a consultant dermatologist at King's College.

"You need to keep an open mind" regarding cutaneous signs and a diagnosis of COVID-19, Bataille, one of the coauthors of the UK report, said in an interview. In general, she considers a low threshold of suspicion appropriate. "If the patient has no past history of skin disease and no other triggers for a rash, then, in a high prevalence area, COVID must be suspected."

In most cases, the rash resolves on its own, but Bataille emphasized the need for individualized care. Even as the risk for life-threatening COVID-19 appears to be diminishing with current variants, cutaneous manifestations can be severe.

"There are cases of long COVID affecting the skin, such as urticaria or a lichenoid erythematopapular rash, both of which can be very pruritic and difficult to control," she said.

Freeman echoed the importance of an individualized approach. She agreed that most cutaneous symptoms are self-limited, but there are exceptions, and treatments vary for the different types of skin involvement.

"I think another point to consider when examining skin lesions is monkey pox. The fact that these are overlapping outbreaks should not be ignored," Freeman advised. "You need to be alert for both."

Visconti, Freeman, and Bataille reported no potential relevant financial relationships.

Study Highlights

  • Researchers used data from the ZOE COVID Study app in the United Kingdom. This app allows UK residents to enter personal information and log the presence of 33 symptoms of COVID-19.
  • Study participants were between the ages of 1 and 90 years.
  • The current study compares reports of participants with and without COVID-19 during the Delta and Omicron surges (June 27 to November 27, 2021 and December 20 to February 23, 2022, respectively).
  • The app specifically inquires about the presence of 5 cutaneous symptoms:
    • Red or purple sores or blisters on the feet or toes (acral rash)
    • Rash on arm or torso (erythematopapular rash)
    • Welts on the face or body (urticarial rash)
    • Unpleasant pins and needles or burning (burning rash)
    • Unusual hair loss
  • The investigators adjusted the study analysis to account for demographic variables, COVID-19 vaccination status, and previous dermatologic disease and its treatment.
  • They compared data from 42,299 confirmed cases of COVID-19 with 156,835 reports from unrelated illnesses during the Delta surge. The respective numbers during the Omicron surge were 75,580 and 123,554.
  • Cutaneous symptoms were reported by 17.6% and 11.4% of participants with COVID-19 during the Delta and Omicron surges, respectively. The respective rates of cutaneous symptoms among participants without COVID-19 were 9% and 9.6%.
  • The adjusted odds ratio (aOR) for cutaneous symptoms in comparing persons with vs without COVID-19 during the Delta surge was 2.29 (95% CI: 2.22, 2.36). The respective aOR during the Omicron surge was not as strong (1.29 [95% CI: 1.26, 1.33]).
  • Of the 5 cutaneous symptoms, COVID-19 had the strongest association with burning rash. All 5 cutaneous symptoms were significantly associated with COVID-19 infection vs. no infection during the Delta surge.
  • In contrast, only burning rash, urticarial rash, and erythematopapular rash were significantly associated with COVID-19 during the Omicron surge, with lower aORs across all symptoms compared with the Delta surge.
  • Cutaneous symptoms of COVID-19 also lasted longer in duration during the Delta vs Omicron surges.
  • Most cutaneous symptoms appeared after other symptoms of COVID-19 during both the Delta and Omicron surges, with an average of 5 to 6 days lag between any symptom and cutaneous symptoms. Fewer than 1% of participants reported a cutaneous symptom as the first symptom of COVID-19.
  • The addition of COVID-19 vaccination as a variable did not substantially alter the risk for cutaneous symptoms of COVID-19. Vaccinated individuals were less likely to report burning rash only.

Clinical Implications

  • In a previous study by Daneshgaran and colleagues published in 2020, the most frequent cutaneous manifestation of COVID-19 was acral sores or blisters of the toes ("COVID toes"), occurring among 40.4% of patients with skin symptoms. The mean age of patients with these symptoms was 23.2 years. Vascular rashes comprised 4% of the sample of patients, and these rashes occurred among older adults. Eruptions resembling erythema multiforme were found in 3.7% of patients and occurred primarily among children.
  • In the current study by Visconti and colleagues, burning rash was the most common cutaneous symptom reported among participants with COVID-19 during the Delta and Omicron surges. Overall, cutaneous symptoms were more common during the Delta vs Omicron surges.
  • Implications for the healthcare team: Members of the healthcare team must be aware that cutaneous symptoms are becoming less common with the Omicron variant but still can occur after the onset of illness. Only burning rash, urticarial rash, and erythematopapular rash were significantly associated with COVID-19 during the Omicron surge compared with the Delta surge.

 

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