Mucocutaneous eruptions may suggest severe disease course in adults with COVID-19

Hospitalized adults with COVID-19, as opposed to those with other acute viral infections, normally present with mucocutaneous eruptions, which may indicate a more severe course of illness, suggests a recent study.

“Although confirmatory studies may be required to assess the generalizability of these observations, this study provides insight into prevalence, morphologic characterization, distribution, and clinical course associated with eruptions in hospitalized adults with COVID-19,” the researchers said.

This prospective cohort study was carried out at two tertiary hospitals between 11 May 2020 and 15 June 2020 to estimate the prevalence of mucocutaneous findings, characterize morphologic patterns, and describe relationship to course in hospitalized COVID-19 patients.

Of the 296 hospitalized adults with COVID-19, 35 (11.8 percent) presented with at least one disease-related eruption, such as ulcer (13/35, 37.1 percent), purpura (9/35, 25.7 percent), necrosis (5/35, 14.3 percent), nonspecific erythema (4/35, 11.4 percent), morbilliform eruption (4/35, 11.4 percent), pernio-like lesions (4/35, 11.4 percent), and vesicles (1/35, 2.9 percent). In addition, these patterns showed anatomic site specificity. [J Am Acad Dermatol 2021;84:946-952]

Several patients with mucocutaneous findings, relative to those without, used mechanical ventilation (61 percent vs 30 percent), used vasopressors (77 percent vs 33 percent), initiated dialysis (31 percent vs 9 percent), had thrombosis (17 percent vs 11 percent), and had in-hospital mortality (34 percent vs 12 percent). These patients were also nearly twice as likely to use mechanical ventilation (adjusted prevalence ratio, 1.98, 95 percent confidence interval, 1.37–2.86; p<0.001).

After adjustment for covariates, differences for other outcomes decreased and did not reach statistical significance.

“Impressions of disease course among adults hospitalized with COVID-19 appear to contrast with our observations in hospitalized children and adolescents with COVID-19 or multisystem inflammatory syndrome in children and rash, in whom presence of mucocutaneous disease may suggest a less severe clinical course,” the researchers noted. [J Am Acad Dermatol 2021;84:408-414]

Previous studies that assessed clinical outcomes in relation to mucocutaneous manifestations in COVID-19 were limited to case series and one cross-sectional study including 53 hospitalized patients with rash from Italy and China. [Br J Dermatol 2020;183:71-77; J Eur Acad Dermatol Venereol 2020;34:e212-e213; J Am Acad Dermatol 2020;83:674-675]

The cross-sectional study, however, did not describe in detail its study methods and clinical outcomes, although a link between mucocutaneous disease and COVID-19 severity was not established. [J Am Acad Dermatol 2020;83:674-675]

A series by the American Academy of Dermatology described worse prognosis among 11 patients with retiform purpura, while a Spanish series of 735 patients observed a higher prevalence of pneumonia, hospital admission, intensive care unit admission, and death among those with livedo, necrosis, and maculopapular eruptions than those with other patterns. [Br J Dermatol 2020;183:71-77]

“However, maculopapular eruptions comprised approximately half of the cases, for which drug-induced eruptions could not be ruled out,” the researchers said. “More than one-third of cases in the series did not have confirmation of COVID-19, and there was limited follow-up time for data on disease course.”

The current study had several limitations. First, the cohort may not be representative of those with milder disease or those who do not require hospitalization. Second, the exact onset of rash from acutely ill patients was not established. Third, duration of illness prior to admission and the variability between time from admission to mucocutaneous examination were not captured.

In addition, the researchers did not perform skin biopsy of the patterns observed. As such, histopathologic correlations for the eruptions could not be provided.