Classification of the Cutaneous Manifestations of COVID-19

A Rapid Prospective Nationwide Consensus Study in Spain With 375 Cases

C. Galván Casas; A. Català; G. Carretero Hernández; P. Rodríguez-Jiménez; D. Fernández-Nieto; A. Rodríguez-Villa Lario; I. Navarro Fernández; R. Ruiz-Villaverde; D. Falkenhain-López; M. Llamas Velasco; J. García-Gavín; O. Baniandrés; C. González-Cruz; V. Morillas-Lahuerta; X. Cubiró; I. Figueras Nart; G. Selda-Enriquez; J. Romaní; X. Fustà-Novell; A. Melian-Olivera; M. Roncero Riesco; P. Burgos-Blasco; J. Sola Ortigosa; M. Feito Rodriguez; I. García-Doval


The British Journal of Dermatology. 2020;183(1):71-77. 

In This Article

Abstract and Introduction


Background: The cutaneous manifestations of COVID -19 disease are poorly characterized.

Objectives: To describe the cutaneous manifestations of COVID -19 disease and to relate them to other clinical findings.

Methods: We carried out a nationwide case collection survey of images and clinical data. Using a consensus we described five clinical patterns. We later described the association of these patterns with patient demographics, the timing in relation to symptoms of the disease, the severity and the prognosis.

Results: The lesions may be classified as acral areas of erythema with vesicles or pustules (pseudo-chilblain) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%). Vesicular eruptions appear early in the course of the disease (15% before other symptoms). The pseudo-chilblain pattern frequently appears late in the evolution of the COVID -19 disease (59% after other symptoms), while the rest tend to appear with other symptoms of COVID -19. The severity of COVID -19 shows a gradient from less severe disease in acral lesions to more severe in the latter groups. The results are similar for confirmed and suspected cases, in terms of both clinical and epidemiological findings. Alternative diagnoses are discussed but seem unlikely for the most specific patterns (pseudo-chilblain and vesicular).

Conclusions: We provide a description of the cutaneous manifestations associated with COVID -19 infection. These may help clinicians approach patients with the disease and recognize cases presenting with few symptoms.


In December 2019, the first cases of pneumonia with unknown cause were reported in Wuhan, China.[1] The new pathogen, called SARS-CoV-2, was isolated from samples of the lower respiratory tract of infected patients,[2] and the resulting disease was called COVID-19 (Coronavirus Disease 2019). SARS-CoV-2 has rapidly spread, reaching the level of a pandemic disease.

COVID-19 can affect different organ systems, probably including the skin. There are few descriptions of the cutaneous manifestations of COVID-19. Twenty per cent of patients in an Italian medical ward had cutaneous lesions, described as rash or urticaria and including one case of 'chickenpox-like' lesions.[3] Other case reports describe a rash mistaken for dengue,[4] acro-ischaemia in children[5] and critical patients,[6] plaques on the heels,[7] and urticaria.[8,9] Most of these reports lack clinical images, due to safety concerns,[10] and they describe few patients in hospital settings.

There is no previous detailed classification or description of the cutaneous manifestations of COVID-19. This information may prove useful to manage patients and to recognize paucisymptomatic patients, and might provide prognostic information. The recognition of paucisymptomatic patients could also be helpful for epidemiological control, especially in areas where diagnostic tests are scarce.[11]

For all of these reasons we conducted a nationwide case collection survey among dermatologists, to allow a quick description of the cutaneous manifestations of COVID-19 disease and to relate them to other clinical findings.