Cutaneous Manifestations in COVID-19–Positive African American Patients

DISCUSSION

The high rate of infectivity of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, resulted in a rapid spread across geographic boundaries, leading to a global pandemic.⁸ The clinical spectrum of COVID-19 ranges from nonapparent or mild symptoms to fatal forms with respiratory failure, septic shock, or multiorgan dysfunction.⁹ The common symptoms of patients with COVID-19 include cough, fever, sputum production, myalgias, fatigue, shortness of breath, sore throat, and headache.¹⁰ However, Henry et al suggest that COVID-19–induced cutaneous manifestations may serve as an indicator of infection before the incubation period of up to 14 days, aiding in timely diagnosis.⁵ Cutaneous manifestations have been reported in case reports and letters to the editor,^2-7,11-18 but formal studies are lacking.

Recalcati reported a 20.4% incidence of cutaneous manifestations in 18 of 88 confirmed COVID-19–positive patients in Italy.² Sachdeva et al conducted a literature review of 72 COVID-19–associated cutaneous manifestations and found that 12.5% of patients presented with cutaneous lesions before symptomatic onset of illness.⁷ Guan et al reported a 0.2% incidence of rash in 1,099 patients from China.¹ The majority of our population was African American patients (80.2%), a racial prevalence that is not reflected in the literature about cutaneous manifestations of COVID-19.

Compared to African Americans, the incidence of skin abnormalities observed in our study was quadrupled in Caucasians. No scientific evidence supports the presence of intrinsic, individual-level factors or increased susceptibility to COVID-19 in various ethnicities.¹⁹ We postulate that the increased incidence of cutaneous manifestations in Caucasians vs African Americans is multifactorial. Social conditions such as limited health care access may result in the underdiagnosis of cutaneous manifestations in African Americans. Additionally, medical training is deficient with regard to identifying cutaneous manifestations in patients with dark complexions.^20,21 We believe a larger number of cutaneous manifestations could have been identified if the medical literature increased awareness of rash presentations in different races and ethnicities. We challenge the medical literature to incorporate images of dermatologic processes in patients with dark complexions.

In our study, only 0.7% of the African American patients—1 infant and 5 adults—were documented to have skin manifestations. The infant exhibited fine erythematous papules on the right side of his face.

The mechanism for COVID-19–induced rashes in infants is not known; however, chilblain rashes seen in children with lupus erythematosus could be attributable to the antiviral and immunostimulatory properties of type I interferons (IFN-I).¹⁸ In adults, an inadequate or delayed IFN-I response can exacerbate preexisting hypercytokinemia, increasing morbidity and mortality.¹⁸

Viral infection with COVID-19 could present as lymphocytic vasculitis similar to the thrombophilic arteritis induced by immune complex–activated cytokines.^7,13 The herpes virus is also known to activate interleukin-1, IFN-gamma, and tumor necrosis factor-alpha, leading to the recruitment of cytotoxic and natural killer cells that target the keratinocytes.¹³ The immune response to infection also leads to Langerhans cells activation, resulting in a state of vasodilation and spongiosis.^7,13

Cutaneous manifestations can also be attributed to COVID-19–induced microthromboses originating in distal organs that may potentially attenuate blood flow to the cutaneous microvasculature and lead to manifestations resembling livedo reticularis.^22,23 Low-grade disseminated intravascular coagulation and hypoxia-related accumulation of deoxygenated blood in venous plexuses may further explain such manifestations.^1,2,23 Magro et al observed extensive complement involvement, membrane attack complex–mediated microvascular endothelial cell injury, and subsequent activation of a clotting pathway, leading to fibrin deposition in patients with severe COVID-19 pneumonitis.²⁴ Further, COVID-19 viral infection could have a vasculitis component. Nevertheless, whether cutaneous symptoms are a secondary consequence of respiratory-related infection or a primary infection of the skin itself remains unclear. A combination of such mechanisms is likely responsible for the cutaneous manifestations in COVID-19–positive individuals.⁷

This study has limitations. Cutaneous manifestations are often more difficult to appreciate in African Americans than Caucasians because of the lack of contrast between the rash and the skin color. The lack of a dermatology service at our institutions could have limited our findings. The information for this study was obtained from medical record review. Patients may not always report a rash, and hospital staff may forget to ask about cutaneous involvement. Because of the high virulence of COVID-19, full-body examinations of the COVID-19–positive patients could have been less thorough compared to hospitalized patients without COVID-19. The cutaneous manifestations identified in this study could have been attributed to medications, allergies, and long-standing dermatologic cutaneous involvement. Patients included in this study were admitted during a peak in the COVID-19 pandemic in the United States, explaining the short study period of 3 months.