What are the main types of skin rashes associated with COVID-19. How can healthcare providers identify and manage COVID-19 related skin issues. What is the link between coronavirus infection and dermatological symptoms.

Overview of COVID-19 Related Skin Manifestations

The novel coronavirus disease (COVID-19) caused by SARS-CoV-2 is primarily known for its respiratory symptoms. However, increasing evidence shows that COVID-19 can also manifest with a variety of skin-related issues. Understanding these dermatological symptoms is crucial for early detection and proper management of the disease.

Researchers have identified several distinct patterns of skin manifestations associated with COVID-19 infection. These cutaneous signs can appear at various stages of the illness and may even precede other typical symptoms in some cases. Recognizing these skin changes can aid in timely diagnosis and treatment of COVID-19.

Classification of COVID-19 Skin Manifestations

Based on current research, COVID-19 related skin manifestations can be broadly classified into six main categories:

1. Urticarial rash
2. Confluent erythematous/maculopapular/morbilliform rash
3. Papulovesicular exanthem
4. Chilblain-like acral pattern
5. Livedo reticularis/racemosa-like pattern
6. Purpuric “vasculitic” pattern

This classification helps healthcare providers in identifying and categorizing the diverse skin symptoms that may appear in COVID-19 patients.

Urticarial Rash in COVID-19 Patients

Urticarial rash, commonly known as hives, is one of the frequently reported skin manifestations in COVID-19 patients. These are raised, itchy welts on the skin that can appear suddenly and change location over time.

Clinical Features and Prevalence

Studies have shown that urticarial rashes account for approximately 16-19% of COVID-19 related skin manifestations. They typically appear simultaneously with other systemic symptoms of COVID-19 and can last for about a week. The rash predominantly affects the trunk and limbs, often sparing the acral sites like hands and feet.

Association with Disease Severity

Interestingly, the presence of urticarial rash has been associated with medium to high severity of COVID-19. This correlation suggests that the appearance of hives could potentially serve as an indicator of disease progression.

Management of Urticarial Rash

Treatment of COVID-19 related urticaria typically involves symptomatic management with antihistamines to relieve itching. In some cases, short courses of oral corticosteroids may be prescribed under medical supervision. It’s crucial to monitor these patients closely as the rash may be an early sign of COVID-19 severity.

Maculopapular and Morbilliform Rashes in COVID-19

Maculopapular and morbilliform rashes are another common dermatological manifestation observed in COVID-19 patients. These rashes appear as flat or slightly raised red areas on the skin, often resembling measles.

Clinical Characteristics

These rashes typically present as widespread erythematous (red) areas with small bumps or papules. They commonly affect the trunk and spread to the limbs. In some cases, the rash may be itchy or mildly painful.

Timing and Duration

Maculopapular rashes usually appear a few days after the onset of other COVID-19 symptoms. They can persist for several days to a week before gradually fading.

Differential Diagnosis

It’s important to note that similar rashes can occur as a side effect of medications or due to other viral infections. Therefore, healthcare providers must consider the patient’s full clinical picture and potential drug reactions when evaluating these rashes.

Papulovesicular Exanthem: A Distinctive COVID-19 Skin Sign

Papulovesicular exanthem, characterized by small, fluid-filled blisters, has emerged as a relatively specific cutaneous manifestation of COVID-19.

Clinical Presentation

This type of rash presents as small vesicles or blisters, often described as similar to chickenpox. The lesions typically appear on the trunk and may spread to the limbs. Unlike chickenpox, these vesicles are usually monomorphic, meaning they are all at the same stage of development.

Pathophysiology

The exact mechanism behind the formation of these vesicles in COVID-19 patients is not fully understood. Some researchers suggest it may be due to direct viral invasion of skin cells, while others propose it could be an immune-mediated response to the virus.

Management and Prognosis

Papulovesicular exanthems in COVID-19 patients generally resolve on their own without specific treatment. However, symptomatic relief with topical treatments may be provided if the rash is uncomfortable. The presence of this rash doesn’t necessarily indicate a more severe course of the disease.

Chilblain-like Acral Lesions: “COVID Toes”

One of the most intriguing cutaneous manifestations of COVID-19 has been the appearance of chilblain-like lesions, particularly on the toes, leading to the colloquial term “COVID toes”.

Clinical Features

These lesions appear as reddish-purple discolorations or swellings on the toes, and sometimes fingers. They can be painful or itchy and may be accompanied by a burning sensation. Interestingly, these lesions often appear in younger patients and those with milder COVID-19 symptoms.

Pathophysiology Theories

The exact cause of COVID toes remains under investigation. Some theories suggest it may be due to microclots in small blood vessels, while others propose it’s an excessive inflammatory response to the virus. The predilection for acral sites (extremities) remains puzzling to researchers.

Course and Management

Chilblain-like lesions typically resolve on their own within a few weeks. Treatment is usually focused on symptom relief, such as using warm compresses or topical corticosteroids if there’s significant inflammation or discomfort.

Livedo Reticularis and Racemosa in COVID-19

Livedo reticularis and livedo racemosa are skin conditions characterized by a net-like pattern of reddish-blue discoloration on the skin. These patterns have been observed in some COVID-19 patients, particularly those with more severe disease.

Distinguishing Features

Livedo reticularis presents as a symmetric, lace-like pattern of discoloration, typically on the legs. Livedo racemosa, on the other hand, shows a more irregular, broken pattern and can affect larger areas of the body. Both are thought to be due to blood flow disturbances in the small vessels of the skin.

Association with Disease Severity

The presence of livedo patterns, especially livedo racemosa, has been associated with more severe COVID-19 cases and potential complications such as blood clotting disorders. This underscores the importance of recognizing these skin signs for proper patient management.

Monitoring and Management

Patients presenting with livedo patterns should be closely monitored for signs of systemic complications. Treatment is generally focused on managing the underlying COVID-19 infection and any associated clotting abnormalities.

Purpuric “Vasculitic” Pattern in COVID-19

The purpuric “vasculitic” pattern refers to skin lesions that resemble those seen in various forms of vasculitis, which is inflammation of blood vessels. This pattern has been observed in some COVID-19 patients, particularly in more severe cases.

Clinical Presentation

These lesions appear as small, reddish-purple spots or patches on the skin that don’t blanch (fade) when pressure is applied. They can occur anywhere on the body but are often seen on the lower legs and feet. In some cases, the lesions may be palpable, feeling slightly raised to the touch.

Pathophysiology

The exact mechanism behind these vasculitic-like lesions in COVID-19 is not fully understood. It’s thought to be related to the virus’s ability to cause inflammation and damage to blood vessels, either directly or through an excessive immune response.

Implications and Management

The presence of purpuric lesions in COVID-19 patients may indicate a more severe course of the disease and potential complications involving the blood vessels. These patients often require closer monitoring and may need additional treatments to address the underlying vascular inflammation.

Diagnostic Challenges and Considerations

Identifying and attributing skin manifestations to COVID-19 can be challenging for healthcare providers. Several factors complicate the diagnostic process:

Timing of Skin Manifestations

Skin symptoms can appear at various stages of COVID-19 infection. Some may precede other symptoms, while others may appear during the active phase of the disease or even during recovery. This variability in timing can make it difficult to establish a clear link to COVID-19.

Similarity to Other Conditions

Many of the skin manifestations associated with COVID-19 can resemble those caused by other viral infections or drug reactions. Healthcare providers must carefully consider the patient’s full clinical picture, including exposure history and medication use, to make an accurate diagnosis.

Lack of Specific Tests

Currently, there are no specific tests to definitively link skin manifestations to COVID-19. Diagnosis often relies on clinical judgment and the presence of other COVID-19 symptoms or a positive SARS-CoV-2 test.

Recommendations for Diagnosis

To improve diagnostic accuracy, healthcare providers are encouraged to:

• Document skin changes with photographs when possible
• Consider skin biopsies in unclear cases
• Correlate skin findings with other COVID-19 symptoms and test results
• Be aware of the possibility of COVID-19 in patients presenting with unusual skin manifestations, even in the absence of respiratory symptoms

Management of COVID-19 Related Skin Manifestations

The management of skin manifestations in COVID-19 patients requires a balanced approach, considering both the dermatological symptoms and the overall course of the viral infection.

General Principles

Treatment is often symptomatic and supportive. The primary focus remains on managing the COVID-19 infection itself. However, addressing skin symptoms can significantly improve patient comfort and quality of life.

Specific Management Strategies

Treatment approaches may vary depending on the type of skin manifestation:

• Urticarial rashes: Antihistamines are typically the first-line treatment. In severe cases, short courses of systemic corticosteroids may be considered.
• Maculopapular rashes: These often resolve on their own. Topical corticosteroids may be used for symptomatic relief if there’s significant itching.
• Chilblain-like lesions: Usually self-limiting. Symptomatic treatment with warm compresses or topical corticosteroids may be helpful.
• Vasculitic lesions: These may require more aggressive management and closer monitoring for systemic complications.

Monitoring and Follow-up

Patients with COVID-19 related skin manifestations should be monitored for progression of both cutaneous and systemic symptoms. Follow-up dermatological evaluation may be necessary in cases of persistent or evolving skin lesions.

Future Perspectives and Research Directions

As our understanding of COVID-19 continues to evolve, so does our knowledge of its dermatological manifestations. Several areas warrant further investigation:

Long-term Skin Effects

Research is needed to determine if COVID-19 can lead to long-term skin issues or exacerbate existing dermatological conditions. Studies focusing on the skin health of COVID-19 survivors will be crucial.

Pathophysiological Mechanisms

More research is required to elucidate the exact mechanisms by which SARS-CoV-2 causes various skin manifestations. This could lead to more targeted treatments and better management strategies.

Predictive Value of Skin Manifestations

Further studies are needed to determine if certain skin manifestations can predict the course or severity of COVID-19. This could help in early identification of patients at risk for complications.

Treatment Efficacy

Clinical trials focusing specifically on the treatment of COVID-19 related skin manifestations are needed to establish evidence-based management protocols.

As the COVID-19 pandemic continues, dermatologists and other healthcare providers must remain vigilant for these varied skin manifestations. Recognizing and properly managing these cutaneous signs can contribute significantly to overall patient care and potentially provide valuable insights into the disease process of COVID-19.

Skin Manifestations Associated with COVID-19: Current Knowledge and Future Perspectives – FullText – Dermatology 2021, Vol. 237, No. 1

Abstract

Background: Coronavirus disease-19 (COVID-19) is an ongoing global pandemic caused by the “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2), which was isolated for the first time in Wuhan (China) in December 2019. Common symptoms include fever, cough, fatigue, dyspnea and hypogeusia/hyposmia. Among extrapulmonary signs associated with COVID-19, dermatological manifestations have been increasingly reported in the last few months. Summary: The polymorphic nature of COVID-19-associated cutaneous manifestations led our group to propose a classification, which distinguishes the following six main clinical patterns: (i) urticarial rash, (ii) confluent erythematous/maculopapular/morbilliform rash, (iii) papulovesicular exanthem, (iv) chilblain-like acral pattern, (v) livedo reticularis/racemosa-like pattern, (vi) purpuric “vasculitic” pattern. This review summarizes the current knowledge on COVID-19-associated cutaneous manifestations, focusing on clinical features and therapeutic management of each category and attempting to give an overview of the hypothesized pathophysiological mechanisms of these conditions.

© 2020 S. Karger AG, Basel

Introduction

In December 2019, a novel zoonotic RNA virus named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) was isolated in patients with pneumonia in Wuhan, China. Since then, the disease caused by this virus, called “coronavirus disease-19” (COVID-19), has spread throughout the world at a staggering speed becoming a pandemic emergency [1]. Although COVID-19 is best known for causing fever and respiratory symptoms, it has been reported to be associated also with different extrapulmonary manifestations, including dermatological signs [2]. Whilst the COVID-19-associated cutaneous manifestations have been increasingly reported, their exact incidence has yet to be estimated, their pathophysiological mechanisms are largely unknown, and the role, direct or indirect, of SARS-CoV-2 in their pathogenesis is still debated. Furthermore, evidence is accumulating that skin manifestations associated with COVID-19 are extremely polymorphic [3]. In this regard, our group proposed the following six main clinical patterns of COVID-19-associated cutaneous manifestations in a recently published review article: (i) urticarial rash, (ii) confluent erythematous/maculopapular/morbilliform rash, (iii) papulovesicular exanthem, (iv) chilblain-like acral pattern, (v) livedo reticularis/racemosa-like pattern, (vi) purpuric “vasculitic” pattern (shown in Fig. 1) [2]. Other authors have attempted to bring clarity in this field, suggesting possible classifications of COVID-19-associated cutaneous manifestations [4-6]. Finally, distinguishing nosological entities “truly” associated with COVID-19 from cutaneous drug reactions or exanthems due to viruses other than SARS-CoV-2 remains a frequent open problem.

Fig. 1.

Clinical features of COVID-19-associated cutaneous manifestations.

Herein, we have striven to provide a comprehensive overview of the cutaneous manifestations associated with COVID-19 subdivided according to the classification by Marzano et al. [2], focusing on clinical features, histopathological features, hypothesized pathophysiological mechanisms and therapeutic management.

Urticarial Rash

Clinical Features and Association with COVID-19 Severity

It is well known that urticaria and angioedema can be triggered by viral and bacterial agents, such as cytomegalovirus, herpesvirus, and Epstein-Barr virus and mycoplasma. However, establishing a cause-effect relationship may be difficult in single cases [7, 8]. Urticarial eruptions associated with COVID-19 have been first reported by Recalcati [9] in his cohort of hospitalized patients, accounting for 16.7% of total skin manifestations. Urticaria-like eruptions have been subsequently described in other cohort studies. Galván Casas et al. [4] stated that urticarial rash occurred in 19% of their cohort, tended to appear simultaneously with systemic symptoms, lasted approximately 1 week and was associated with medium-high severity of COVID-19. Moreover, itch was almost always present [4]. Freeman et al. [10] found a similar prevalence of urticaria (16%) in their series of 716 cases, in which urticarial lesions predominantly involved the trunk and limbs, relatively sparing the acral sites. As shown in Table 1, urticaria-like signs accounted for 11.9% of cutaneous manifestations seen in an Italian multicentric cohort study on 159 patients [unpubl. data]. Urticarial lesions associated with fever were reported to be early or even prodromal signs of COVID-19, in the absence of respiratory symptoms, in 3 patients [11-13]. Therefore, the authors of the reports suggested that isolation is needed for patients developing such skin symptoms if COVID-19 infection is suspected in order to prevent possible SARS-CoV-2 transmission [11-13]. COVID-19-related urticaria occurred also in a familial cluster, involving 2 patients belonging to a Mexican family of 5 people, all infected by SARS-CoV-2 and suffering also from anosmia, ageusia, chills and dizziness [14]. Angioedema may accompany COVID-19-related urticaria, as evidenced by the case published in June 2020 of an elderly man presenting with urticaria, angioedema, general malaise, fatigue, fever and pharyngodynia [15]. Urticarial vasculitis has also been described in association with COVID-19 in 2 patients [16].

Table 1.

Prevalence of different clinical patterns in the main studies on COVID-19-associated cutaneous manifestations

Histopathological Findings

Histopathological studies of urticarial rashes are scant. In a 60-year-old woman with persistent urticarial eruption and interstitial pneumonia who was not under any medication, Rodriguez-Jiménez et al. [17] found on histopathology slight vacuolar interface dermatitis with occasional necrotic keratinocytes curiously compatible with an erythema multiforme-like pattern. Amatore et al. [18] documented also the presence of lichenoid and vacuolar interface dermatitis, associated with mild spongiosis, dyskeratotic basal keratinocytes and superficial perivascular lymphocytic infiltrate, in a biopsy of urticarial eruption associated with COVID-19 (Fig. 2).

Fig. 2.

Histopathological features of the main cutaneous patterns associated with COVID-19. a Urticarial rash. b Confluent erythematous maculopapular/morbilliform rash. c Chilblain-like acral lesions. d Purpuric “vasculitic” pattern.

Therapeutic Options

Shanshal [19] suggested low-dose systemic corticosteroids as a therapeutic option for COVID-19-associated urticarial rash. Indeed, the author hypothesized that low-dose systemic corticosteroids, combined with nonsedating antihistamines, can help in managing the hyperactivity of the immune system in COVID-19, not only to control urticaria, but also to improve possibly the survival rate in COVID-19.

Confluent Erythematous/Maculopapular/Morbilliform Rash

Clinical Features and Association with COVID-19 Severity

Maculopapular eruptions accounted for 47% of all cutaneous manifestations in the cohort of Galván Casas et al. [4], for 44% of the skin manifestations included in the study by Freeman et al. [10], who further subdivided this group of cutaneous lesions into macular erythema (13%), morbilliform exanthems (22%) and papulosquamous lesions (9%), and for 30. 2% of the cutaneous manifestations included in the unpublished Italian multicentric study shown in Table 1. The prevalence of erythematous rash was higher in other studies, like that published by De Giorgi et al. [20] in May 2020, in which erythematous rashes accounted for 70% of total skin manifestations. In the series by Freeman et al. [10], macular erythema, morbilliform exanthems and papulosquamous lesions were predominantly localized on the trunk and limbs, being associated with pruritus in most cases. In the same series, these lesions occurred more frequently after COVID-19 systemic symptoms’ onset [21]. The clinical picture of the eruptions belonging to this group may range from erythematous confluent rashes to maculopapular eruptions and morbilliform exanthems. Erythematous lesions may show a purpuric evolution [21] or coexist from the beginning with purpuric lesions [22]. Erythematous papules may also be arranged in a morbilliform pattern [23]. In a subanalysis of the COVID-Piel Study [4] on maculopapular eruptions including also purpuric, erythema multiforme-like, pityriasis rosea-like, erythema elevatum diutinum-like and perifollicular eruptions, morbilliform exanthems were the most frequent maculopapular pattern (n = 80/176, 45. 5%) [24]. This study showed that in most cases lesions were generalized, symmetrical and started on the trunk with centrifugal progression. In the same subanalysis, hospital admission due to pneumonia was very frequent (80%) in patients with a morbilliform pattern [24]. In this group, the main differential diagnoses are represented by exanthems due to viruses other than SARS-CoV-2 and drug-induced cutaneous reactions.

Histopathological Findings

Histopathology of erythematous eruptions was described by Gianotti et al. [25], who found vascular damage in all the 3 cases examined. A clinicopathological characterization of late-onset maculopapular eruptions related to COVID-19 was provided also by Reymundo et al. [26], who observed a mild superficial perivascular lymphocytic infiltrate on the histology of 4 patients. In contrast, Herrero-Moyano et al. [27] observed dense neutrophilic infiltrates in 8 patients with late maculopapular eruptions. The authors of the former study postulated that this discrepancy could be attributable to the history of new drug assumptions in the series of Herrero-Moyano et al. [26] (Fig. 2).

Therapeutic Options

The management of confluent erythematous/maculopapular/morbilliform rash varies according to the severity of the clinical picture. Topical corticosteroids can be sufficient in most cases [23], systemic corticosteroids deserving to be administered just in more severe and widespread presentations.

Papulovesicular Exanthem

Clinical Features and Association with COVID-19 Severity

COVID-19-associated papulovesicular exanthem was first extensively reported in a multicenter Italian case series of 22 patients published in April 2020 [28]. In this article, it was originally described as “varicella-like” due to resemblance of its elementary lesions to those of varicella. However, the authors themselves underlined that the main clinical features of COVID-19-associated papulovesicular exanthem, namely trunk involvement, scattered distribution and mild/absent pruritus, differentiated it from “true” varicella. In this study, skin lesions appeared on average 3 days after systemic symptoms’ onset and healed after 8 days, without scarring sequelae [28]. The exact prevalence of papulovesicular exanthems is variable. Indeed, in a cohort of 375 patients with COVID-19-associated cutaneous manifestations [4], patients with papulovesicular exanthem were 34 (9%), while they were 3 out of 52 (5.8%), 1 out of 18 (5.5%) and 2 out of 53 (4%) in the cohorts published by Askin et al. [29], Recalcati [9] and De Giorgi et al. [20], respectively. In the Italian multicentric study shown in Table 1, papulovesicular rash accounted for 18.2% of skin manifestations. Furthermore, even if papulovesicular exanthem tends to involve more frequently the adult population, with a median age of 60 years in the study by Marzano et al. [28], also children may be affected [30]. Galván Casas et al. [4] reported that vesicular lesions generally involved middle-aged patients, before systemic symptoms’ onset in 15% of cases, and were associated with intermediate COVID-19 severity. Fernandez-Nieto et al. [31] conducted a prospective study on 24 patients diagnosed with COVID-19-associated vesicular rash. In this cohort, the median age (40.5 years) was lower than that reported by Marzano et al. [28], and COVID-19 severity was mostly mild or intermediate, with only 1 patient requiring intensive unit care support. In our cohort of 22 patients, a patient was hospitalized in the intensive care unit and 3 patients died [28]. Vesicular rash, which was generally pruritic, appeared after COVID-19 diagnosis in most patients (n = 19; 79.2%), with a median latency time of 14 days [31]. Two different morphological patterns were found: a widespread polymorphic pattern, more common and consisting of small papules, vesicles and pustules of different sizes, and a localized pattern, less frequent and consisting of monomorphic lesions, usually involving the mid chest/upper abdominal region or the back [31].

Histopathological Findings

Mahé et al. [32] reported on 3 patients with typical COVID-19-associated papulovesicular rash, in which the histological pattern of skin lesions showed prominent acantholysis and dyskeratosis associated with the presence of an unilocular intraepidermal vesicle in a suprabasal location. Based on these histopathological findings, the authors refused the term “varicella-like rash” and proposed a term which was more suitable in their view: “COVID-19-associated acantholytic rash.” Histopathological findings of another case of papulovesicular eruption revealed extensive epidermal necrosis with acantholysis and swelling of keratinocytes, ballooning degeneration of keratinocytes and signs of endotheliitis in the dermal vessels [33]. Acantholysis and ballooned keratinocytes were found also by Fernandez-Nieto et al. [31] in 2 patients.

The differential diagnosis with infections caused by members of the Herpesviridae family has been much debated. Tammaro et al. [34] described the onset of numerous, isolated vesicles on the back 8 days after COVID-19 diagnosis in a Barcelonan woman and reported on 2 patients from Rome presenting with isolated, mildly pruritic erythematous-vesicular lesions on their trunk, speculating that these manifestations might be due to viruses belonging to the Herpesviridae family. On the other hand, classic herpes zoster has been reported to complicate the course of COVID-19 [35].

The controversy regarding the role of herpesvirus in the etiology of papulovesicular exanthems fuelled an intense scientific debate. Indeed, some authors raised the question whether papulovesicular exanthem associated with COVID-19 could be diagnosed without ruling out varicella zoster virus and herpes simplex virus with Tzanck smear or polymerase chain reaction (PCR) for the Herpesviridae family in the vesicle fluid or on the skin [36, 37]. In our opinion, even if seeking DNA of Herpesviridae family members is ideally advisable, clinical diagnosis may be reliable in most cases, and the role of herpes viruses as mere superinfection in patients with dysfunctional immune response associated with COVID-19 needs to be considered [38]. To our knowledge, SARS-CoV-2 has not been hitherto isolated by means of reverse transcriptase PCR in the vesicle fluid of papulovesicular rash [33, 31].

Therapeutic Options

No standardized treatments for COVID-19-related papulovesicular exanthem are available, also given that it is self-healing within a short time frame. Thus, a “wait-and-see” strategy may be recommended.

Chilblain-Like Acral Pattern

Clinical Features and Association with COVID-19 Severity

COVID-19-related chilblain-like acral lesions have been first described in a 13-year-old boy by Italian authors in early March [39]. Since then, several “outbreaks” of chilblain-like acral lesions chiefly involving young adults and children from different countries worldwide have been posted on social media and published in the scientific literature [40-46]. Caucasians seem to be significantly more affected than other ethnic groups [47, 48]. Chilblain-like acral lesions were the second most frequent cutaneous manifestation (n = 46/159; 28.9%) in the multicenter Italian study shown in Table 1. Different pathogenetic hypotheses, including increased interferon release induced by COVID-19 and consequent cytokine-mediated inflammatory response, have been suggested [49]. Furthermore, virus-induced endothelial damage as well as an obliterative microangiopathy and coagulation abnormalities could be mechanisms involved in the pathogenesis of these lesions [50]. Chilblain-like acral lesions associated with COVID-19 were depicted as erythematous-violaceous patches or plaques predominantly involving the feet and, to a lesser extent, hands [40, 51]. Rare cases of chilblain-like lesions involving other acral sites, such as the auricular region, were also reported [52]. The occurrence of blistering lesions varied according to the case series analyzed; Piccolo et al. [51], indeed, reported the presence of blistering lesions in 23 out of 54 patients, while other authors did not describe bullous lesions in their series [40, 47]. Dermoscopy of these lesions revealed the presence of an indicative pattern represented by a red background area with purpuric globules [53]. Pain/burning sensation as well as pruritus were commonly reported symptoms, even if a small proportion of patients presented with asymptomatic lesions [40, 44, 47]. Unlike other COVID-19-related cutaneous findings, chilblain-like acral lesions tended to mostly involve patients without systemic symptoms.

The frequent occurrence of chilblain-like lesions in the absence of cold exposure and the involvement of patients without evident COVID-19-related symptoms raised the question whether these manifestations were actually associated with SARS-CoV-2 infection.

Histopathological and Pathophysiological Findings

Chilblain-like lesions share many histopathological features with idiopathic and autoimmunity-related chilblains, including epidermal necrotic keratinocytes, dermal edema, perivascular and perieccrine sweat gland lymphocytic inflammation. Vascular changes such as endotheliitis and microthrombi may be found [40, 45, 54, 55] (Fig. 2).

Data on the real association between chilblain-like acral lesions and COVID-19 are controversial.

The first case series failed to perform SARS-CoV-2 testing in all patients, also due to logistic problems and economic restrictions, and diagnosed COVID-19 only in a minority of patients with chilblain-like acral lesions [40, 44, 47]. Subsequently, some authors systematically sought SARS-CoV-2 with serology and/or nasopharyngeal swab in patients with chilblain-like acral lesions. In their cohort of 38 children with pseudo-chilblain, Caselli et al. [56] showed no evidence of SARS-CoV-2 infection by PCR or serology. Chilblain-like acral lesions appeared not to be directly associated with COVID-19 also in the case series by Herman et al. [57]. These authors failed to detect SARS-CoV-2 in nasopharyngeal swabs and skin biopsies and demonstrated no specific anti-SARS-CoV-2 immunoglobulin IgM or IgG antibodies in blood samples. Therefore, they concluded that lifestyle changes associated with lockdown measures might be a possible explanation for these lesions [57]. Similar results were obtained also by other authors [58-63] weakening the hypothesis of a direct etiological link between SARS-CoV-2 and chilblain-like acral lesions.

Opposite conclusions have been drawn by Colmenero et al. [64], who demonstrated by immunohistochemistry and electron microscopy the presence of SARS-CoV-2 in endothelial cells of skin biopsies of 7 children with chilblain-like acral lesions, suggesting that virus-induced vascular damage and secondary ischemia could explain the pathophysiology of these lesions.

In the absence of definitive data on chilblain-like acral lesions’ pathogenesis, the occurrence of such lesions should prompt self-isolation and confirmatory testing for SARS-CoV-2 infection [65].

Therapeutic Options

In the absence of significant therapeutic options for chilblain-like acral lesions associated with COVID-19 and given their tendency to spontaneously heal, a “wait-and-see” strategy may be suggested.

Livedo Reticularis/Racemosa-Like Pattern

Clinical Features and Association with COVID-19 Severity

Livedo describes a reticulate pattern of slow blood flow, with consequent desaturation of blood and bluish cutaneous discoloration. It has been divided into: (i) livedo reticularis, which develops as tight, symmetrical, lace-like, dusky patches forming complete rings surrounding a pale center, generally associated with cold-induced cutaneous vasoconstriction or vascular flow disturbances such as seen in polycythemia and (ii) livedo racemosa, characterized by larger, irregular and asymmetrical rings than seen in livedo reticularis, more frequently associated with focal impairment of blood flow, as it can be seen in Sneddon’s syndrome [66].

In our classification, the livedo reticularis/racemosa-like pattern has been distinguished by the purpuric “vasculitic” pattern because the former likely recognizes a occlusive/microthrombotic vasculopathic etiology, while the latter can be more likely considered the expression of a “true” vasculitic process [2]. Instead, the classification by Galván Casas et al. [4] merged these two patterns into the category “livedo/necrosis”.

In a French study on vascular lesions associated with COVID-19, livedo was observed in 1 out of 7 patients [43]. In the large cases series of 716 patients by Freeman et al. [10], livedo reticularis-like lesions, retiform purpura and livedo racemosa-like lesions accounted for 3.5, 2.6 and 0.6% of all cutaneous manifestations, respectively. In the multicentric Italian study, livedo reticularis/racemosa-like lesions accounted for 2.5% of cutaneous manifestations (Table 1).

The pathogenic mechanisms at the basis of small blood vessel occlusion are yet unknown, even if neurogenic, microthrombotic or immune complex-mediated etiologies have been postulated [67].

Livedo reticularis-like lesions are frequently mild, transient and not associated with thromboembolic complications [68, 69]. On the contrary, livedo racemosa-like lesions and retiform purpura have often been described in patients with severe coagulopathy [60-72].

Histopathological and Pathophysiological Findings

The histopathology of livedoid lesions associated with COVID-19 has been described by Magro et al. [73], who observed in 3 patients pauci-inflammatory microthrombotic vasculopathy. The same group demonstrated that in the thrombotic retiform purpura of patients with severe COVID-19, the vascular thrombosis in the skin and internal organs is associated with a minimal interferon response permitting increased viral replication with release of viral proteins that localize to the endothelium inducing widespread complement activation [74], which is frequent in COVID-19 patients and probably involved in the pathophysiology of its clinical complications [75].

Therapeutic Options

In view of the absence of significant therapeutic options for livedo reticularis/racemosa-like lesions associated with COVID-19, a “wait-and-see” strategy may be suggested.

Purpuric “Vasculitic” Pattern

Clinical Features and Association with COVID-19 Severity

The first COVID-19-associated cutaneous manifestation with purpuric features was reported by Joob et al. [76], who described a petechial rash misdiagnosed as dengue in a COVID-19 patient. Purpuric lesions have been suggested to occur more frequently in elderly patients with severe COVID-19, likely representing the cutaneous manifestations associated with the highest rate of COVID-19-related mortality [4]. This hypothesis is corroborated by the unfavorable prognosis observed in several cases reported in the literature [77, 78].

The purpuric pattern reflects the presence of vasculitic changes probably due to the direct damage of endothelial cells by the virus or dysregulated host inflammatory responses induced by COVID-19.

These lesions are likely to be very rare, representing 8.2% of skin manifestations included in the Italian multicentric study shown in Table 1. In their case series of 7 patients with vascular skin lesions related to COVID-19, Bouaziz et al. [43] reported 2 patients with purpuric lesions with (n = 1) and without (n = 1) necrosis. In the series by Freeman et al. [10], 12/716 (1.8%) and 11/716 (1.6%) cases of patients with palpable purpura and dengue-like eruption, respectively, have been reported. Galván Casas et al. [4] reported 21 patients with “livedo/necrosis,” most of whom presenting cutaneous signs in concomitance with systemic symptoms’ onset.

Purpuric lesions may be generalized [79], localized in the intertriginous regions [80] or arranged in an acral distribution [81]. Vasculitic lesions may evolve into hemorrhagic blisters [77]. In most severe cases, extensive acute necrosis and association with severe coagulopathy may be seen [78]. Dermoscopy of purpuric lesions revealed the presence of papules with incomplete violaceous rim and a central yellow globule [82].

Histopathological Findings

When performed, histopathology of skin lesions showed leukocytoclastic vasculitis [77, 79], severe neutrophilic infiltrate within the small vessel walls and in their proximity [77], intense lymphocytic perivascular infiltrates [81], presence of fibrin [79, 81] and endothelial swelling [82] (Fig. 2).

Therapeutic Options

Topical corticosteroids have been successfully used for treating mild cases of purpuric lesions [80]. Cases with necrotic-ulcerative lesions and widespread presentation may be treated with systemic corticosteroids.

Other COVID-19-Associated Cutaneous Manifestations

Other peculiar rare COVID-19-related cutaneous manifestations that cannot be pigeonholed in the classification proposed by our group [2] include, among others, the erythema multiforme-like eruption [83], pityriasis rosea-like rash [84], multi-system inflammatory syndrome in children [85], anagen effluvium [86] and a pseudoherpetic variant of Grover disease [87]. However, the spectrum of possible COVID-19-associated skin manifestations is likely to be still incomplete, and it is expected that new entities associated with this infection will be described.

Conclusion

COVID-19-associated cutaneous manifestations have been increasingly reported in the last few months, garnering attention both from the international scientific community and from the media. A few months after the outbreak of the pandemic, many narrative and systematic reviews concerning the dermatological manifestations of COVID-19 have been published [2, 3, 6, 88-91]. A summary of clinical features, histopathological findings, severity of COVID-19 systemic symptoms and therapeutic options of COVID-19-related skin manifestations has been provided in Table 2.

Table 2.

Summary of clinical features, histopathological findings, severity of COVID-19 systemic symptoms and therapeutic options of COVID-19-related skin manifestations

Albeit several hypotheses on pathophysiological mechanisms at the basis of these skin findings are present in the literature [50, 92, 93], none of them is substantiated by strong evidence, and this field needs to be largely elucidated. Moreover, cutaneous eruptions due to viruses other than SARS-CoV-2 [35, 37] or drugs prescribed for the management of this infection [94, 95] always need to be ruled out.

Experimental pathophysiological studies and clinical data derived from large case series are still needed for shedding light onto this novel, underexplored and fascinating topic.

Key Message

Although COVID-19-associated cutaneous manifestations have been increasingly reported, their pathophysiological mechanisms need to be extensively explored. The conditions may be distinguished in six clinical phenotypes, each showing different histopathological patterns.

Acknowledgment

We would like to thank Dr. Cosimo Misciali, Dr. Paolo Sena and Prof. Pietro Quaglino for kindly providing us with histopathological pictures.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This paper did not receive any funding.

Author Contributions

Giovanni Genovese wrote the paper with the contribution of Chiara Moltrasio. Angelo Valerio Marzano and Emilio Berti supervised the work and revised the paper for critical revision of important intellectual content.

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Author Contacts

Angelo Valerio Marzano

Dermatology Unit

Università degli Studi di Milano

Via Pace 9, IT–20122 Milan (Italy)

[email protected]

Article / Publication Details

First-Page Preview

Received: September 01, 2020
Accepted: November 10, 2020
Published online: November 24, 2020

Issue release date: January 2021

Number of Print Pages: 12

Number of Figures: 2

Number of Tables: 2

ISSN: 1018-8665 (Print)
eISSN: 1421-9832 (Online)

For additional information: https://www.karger.com/DRM

Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.

Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

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Lack of darker skin in textbooks, journals harms patients of color

When dermatologist Jenna Lester learned that rashes on skin and toes were a symptom of Covid-19, she started searching the medical literature for images of what the rashes looked like on Black skin so she’d recognize it in her Black patients. She couldn’t find a single picture.

“I was frustrated because we know Covid-19 is disproportionately impacting communities of color,” said Lester, an assistant professor of dermatology at the University of California, San Francisco who recently published her analysis. “I felt like I was seeing a disparity being built right before my eyes.”

The dearth of images in the Covid-19 literature is just the newest example of the glaring lack of representation of Black and brown skin that has persisted in dermatology research journals and textbooks for decades. The issue is coming under closer scrutiny now as dermatologists, like many physicians, grapple more openly with systemic racism and the health disparities it is causing in their field.

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“Black Lives Matter is forcing a lot of people to look inward and say, ‘Where are our shortcomings?’” said Nada Elbuluk, an associate professor of clinical dermatology at the University of Southern California and the founder of a diversity and inclusion program in her department. “Dermatology is no different.”

The discrimination in her specialty extends beyond images and gaps in training, to restrictive insurance coverage for skin conditions that affect people with heavily pigmented skin, and to the many dermatologists who don’t accept patients with Medicaid.

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It may be no surprise that a field that focuses on skin is now reckoning with skin color. In dermatology, where images are critical for diagnoses, the lack of images of darker skin poses a roadblock to proper treatment and medical education. Skin conditions that involve redness or pinkness in light skin can be subtler or harder to see in dark skin, and physicians who haven’t been adequately trained with such images are prone to misdiagnose people of color. “We absolutely need a diversity of images,” said Elbuluk.

An analysis of textbooks by Jules Lipoff, an assistant professor of clinical dermatology at the University of Pennsylvania, showed the percentage of images of dark skin ranged from 4% to 18%. “We are not teaching (and possibly not learning) skin of color,” Lester wrote in a separate analysis she conducted. Many worry the field’s shift toward using artificial intelligence to aid diagnosis of disease will further deepen the divide, because the machine learning algorithms are trained with datasets consisting primarily of fair-skinned images.

Dermatologist Jenna Lester treats Geoffry Blair Hutto at the UCSF skin of color clinic. Courtesy Barbara Ries, UCSF

It gets worse. While many textbooks depict the vast majority of skin diseases using light skin, there is one notable exception: Black skin is more often used to depict sexually transmitted diseases, a glaring example of stereotyping that is all the more painful given the U.S. government’s complicity in the notorious Tuskegee experiments that left syphilis untreated for decades in a group of poor, Black men.

Lipoff’s analysis, published this year, showed many dermatology textbooks had zero images of dark skin with acne, psoriasis, or dermatitis. When it came to syphilis, however, many books relied heavily on images of dark skin. Lester’s analysis found that while 28% of images of infectious diseases used images of darker skin, the number of depictions of dark skin was twice as high for infections that were sexually transmitted.

“In the textbooks I used in medical school, every penis was a Black penis showing an STD. We’ve got to stop that,” said Susan Taylor, a pioneer in the push for better dermatologic care for patients with dark skin and the Sandra Lazarus professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania.

Considered a trailblazer in the field of dermatology, Taylor established the nation’s first “Skin of Color” dermatology clinic at Mount Sinai in New York in the late 1990s. In 2004, she founded the Skin of Color Society to help educate fellow dermatologists about how to treat patients of color, push for research and clinical trials to include people with darker skin, and mentor and encourage medical students of color to enter dermatology, where only 3% of practitioners are Black and 4% are Hispanic. “These are really abysmal numbers,” Taylor said. “That’s got to change.”

Taylor is also the lead author of the textbook Dermatology for Skin of Color, a guide considered invaluable by many dermatologists. But even those who rely on the book say it’s frustrating that a separate book on dark skin is still required — when as a nation we are just a few decades away from a majority of residents having skin of color.

“This is the white patient treated as the default and the Black patient as the asterisk,” said Lipoff. “You can’t make skin of color a lecture that students get once a year. It can’t be ‘otherized’ or put in a separate textbook.”

Taylor agrees. “Nothing would make me happier than to not have to publish another edition of that book,” she said.

Dermatologists say the lack of images is one reason why many conditions, including Lyme disease, spider bites, and cancers can go misdiagnosed or underdiagnosed in darker skinned patients, sometimes with dangerous results. The five-year melanoma survival rate for Black patients is just 70% compared with 94% for white patients.

The mother of a mixed-race 13-year-old from Connecticut said she was told by her child’s pediatrician when she was 8 that the white patches on her skin were pityriasis alba, a skin rash that’s usually not considered a serious condition. She was given a lotion, but the skin patches never went away. “I kept going online and looking at things but I couldn’t see anyone with issues that looked like hers,” said the mother, who didn’t want her name used to protect the girl’s privacy. “And the doctor was casual about it.”

Partly because of insurance issues, and partly because the mother thought there was nothing to worry about, it took five years before her daughter’s white patches were properly diagnosed: She had T-cell lymphoma, a cancer. While she will require maintenance light therapy for life, her overall prognosis is good. But her case highlights the difficult and sometimes frightening challenge many patients of color face to get a proper dermatologic diagnosis.

“Black Lives Matter is forcing a lot of people to look inward and say, ‘Where are our shortcomings?’ Dermatology is no different.”

Nada Elbuluk, associate professor of clinical dermatology at USC

When Ellen Buchanan Weiss noticed patches on the dark brown skin of her toddler son, she wondered if it was eczema, or something more serious. “I Googled it and noticed immediately the pictures were all of white skin,” she said. “I Googled other conditions and it was the same. No matter what I searched, there were almost no images of dark skin.”

The patches did turn out to be eczema and were easily treated. Still, the disparity bothered her for months. About a year ago, Weiss, a stay-at-home mom in Raleigh, N.C., decided to create an Instagram account called “Brown Skin Matters.” She posted images of skin conditions in darker skin next to images of the same condition in white skin and asked followers to send in more photos. The account exploded almost immediately.

“I’ve had tons of medical schools, physicians, nurses, and pharmacists all contact me saying this was useful,” she said. “I never thought this was going to become a diagnostic tool.”

Instagram is not exactly the best platform for making medical diagnoses, so Weiss is now working with medical experts to help create a more rigorous and searchable web-based tool for diagnosis of skin diseases in darker skin. It still floors Weiss that she, a person with no medical background, is at the center of it. “It’s curious to me, and troubling, that this is 2020 and this gap is still here,” she said. “Some large medical institution should have been taking care of this, not me.”

The issue of textbooks failing to adequately represent skin of color is not a new one. Yet Lipoff’s study compared today’s textbooks with those of 15 years ago and found little has changed. Jean Bolognia, a professor of dermatology at the Yale School of Medicine, has spent more than two decades editing the widely used textbook, Dermatology; she said providing a wide spectrum of skin tones is critical and something she’s worked hard to include, though she acknowledged there’s more work to do.

“I’m not saying it’s perfect, but we’ve been working really hard for over 15 years to show the whole spectrum,” said Bolognia, who is now working on the fifth edition of the textbook. “I feel you can always do better and I realize I don’t have enough images of Asian skin, so that is something I’m addressing.”

Bolognia said she tries to include photos of the same condition in darkly pigmented and lightly pigmented skin, cropped exactly the same way and side-by-side for comparison so readers can see how the same condition can appear significantly different on darker skin. She also includes many more images of dark skin of conditions, like cutaneous lupus or scarring folliculitis, that are more likely to affect Black people.

Comparison of atopic dermatitis in infants with darkly pigmented versus lightly pigmented skin, from the widely used textbook, Dermatology. Courtesy Bolognia JL, Schaffer JV, and Cerroni L, eds. Dermatology. 4th ed. Elsevier

Bolognia said she is extremely sensitive about not stigmatizing people of color by using only images of darkly pigmented skin to illustrate sexually transmitted diseases or drug users. “I noticed this as a student, the images of STDs were nearly all of patients with darkly pigmented skin, but the people I saw with syphilis were often fair-skinned,” she said. “I wondered about the possibility that pictures were being taken of individuals who were less likely to say no.”

The field’s other widely used textbook is Andrews’ Diseases of the Skin. That book’s lead author, William James, is a longtime champion of diversity in dermatology, according to his colleagues at Penn, who include Taylor and Lipoff. James said representing a variety of skin tones was an important issue, but said authors were challenged by limits placed on the number of photos by textbook publishers and because findings of redness or pinkness can be hard to see in images of darker skin. “Deciding if an entity is represented at all, or more than once, is always difficult,” he said in an email.

James said his textbook includes more photos of Black skin than white skin in conditions that are more common in Black patients, and noted that eight of 14 photos of syphilis are in lighter skin.

Agrowing number of dermatologists are following Taylor’s lead and opening skin of color clinics that provide care for darker-skinned patients. Lester opened one at UCSF last year. Elbuluk has worked at or founded three skin of color clinics throughout her training and early career, including at Penn, NYU Medical School, and, in 2018, at USC, where she hopes to also spur much-needed clinical research on darker skin. “It’s surprising to me when large cities don’t have these,” Elbuluk said.

There are many reasons why people of color, particularly those who do not have private health insurance, lack access to dermatologists. Lipoff, who has examined the issue, said many dermatologists do not take Medicaid. Racial bias that discourages the treatment of Black patients, he said, is literally built into the physician reimbursement system. Many conditions that affect darker skin are often not covered by insurance because they are considered cosmetic.

Meanwhile, the highest revenue procedures, Lipoff said, include those for the diagnosis and treatment of skin cancer, which is more likely to occur in white patients. This difference in how procedures are valued and reimbursed, he said, is a perfect example of structural racism that drives practices to directly and indirectly focus on white patients and marginalize Black patients. “If Black patients earned practices three times the revenue,” he said, “the disparity would disappear overnight.”

“It’s curious to me, and troubling, that this is 2020 and this gap is still here. Some large medical institution should have been taking care of this, not me.”

Ellen Buchanan Weiss, Raleigh resident who created the “Brown Skin Matters” Instagram account

Until it does, physicians who run skin of color clinics are hoping to address the lack of care, and poor care, Black and brown patients have received. The clinics are a welcome addition to people like Dar Bray, a 45-year-old behavioral therapist and darker-skinned Black man from Los Angeles.

Bray had dealt for years with deep and persistent scars caused by acne, trying bleaching creams and expensive cosmetic products, all with no success. “I went to so many doctors who didn’t know what to do with my skin. All the pictures they had on their wall were fair-skinned people,” Bray said. “It didn’t feel like racism, it felt like just plain ignorance.”

Seeing Elbuluk, he said, was immediately different. Bray is now undergoing chemical peels to remove scarring and using simple (and inexpensive) cleansers and moisturizers, and says he sees a huge improvement in his skin. He’s also wearing sunscreen, something no physician had ever told him was necessary; like many, he had believed the myth “Black don’t crack.” “When I went to the beach, I never wore sunscreen,” he said. “Now I have years of sun damage.”

Mistrust of white physicians led Gregory Hines, a 63-year-old longshoreman who lives in Oakland, to go years without seeing a doctor about growths under his arm, on his back, and on his neck, even as they puffed up and became, in his words “kind of weird and ugly.”

“I experience it a lot, going to doctors — especially white, male doctors — they assume they know more than you. They assume they already know what your problem is the minute you walk through the door,” he said.

When he heard UCSF’s Skin of Color clinic had opened, he was willing to give it a try. “When Dr. Lester walked in, I said, ‘Whoa, this is great,’” he said. “I wanted a Black doctor who understands Black skin.”

Lester ended up removing the masses, one of which was nearly as large as a golf ball, and sent them for tests to see if they were cancerous. Fortunately, they were not.

Lester is the only Black dermatologist in San Francisco. She’s hoping that will change after her current crop of residents decides where they will establish their practices. Her Black patients, she said, are often shocked when she walks in the door.

“I’ve had patients ask if they can take a picture with me to show their grandkids,” she said. “They want to talk all about me and how I got here, and I have to say, ‘No, this time is for you.’”

Wrestling and Skin Conditions – What Is THAT?

All of these skin diseases MAY NOT BE COVERED FOR COMPETITION!

Report anything suspicious to your athletic trainer or physician ASAP so you can stay competitive!

The sport of wrestling requires close skin-to-skin contact amongst opponents. This close contact means there is a high possibility of catching or spreading a variety of skin conditions amongst competitors. Various different common skin conditions are outlined below, so that you can be aware, identify and get treatment for as soon as possible, so that you can stay on the mat and not on the sidelines.

Herpetic Lesions

Herpetic Lesions (aka herpes simplex, herpes zoster, herpes gladiatorium, cold sore/fever blister) are a viral infection transmitted by direct contact and may appear ANYWHERE ON THE BODY.

Signs and Symptoms:

• Lesion: Numerous clustered vesicles (blisters) filled with clear fluid on a reddened background. The vesicles continue to develop for 7-10 days and eventually become dry, crusted lesions. Recurrent outbreaks are sometimes preceded by irritability, headache, and tingling, burning and/or itching of the skin at the site of recurrence
• Other symptoms may mimic a mild viral illness with fever, joint aches and pains, sore throat, swollen lymph nodes near the affected area and inflammation of the eyes

Return to Play Guidelines:

• Initial outbreaks require minimum of 10-14 days of treatment with oral antiviral medication as prescribed by a physician
• Recurrent outbreaks must complete a minimum 120 hours (5 days) oral antiviral medication
• Must be free of fever, swollen lymph nodes, malaise (feeling ill), etc.
• Existing lesions must be covered in a dry crust (scab), with no oozing or discharge and no new blisters developed in past 72 hours (3 days)
• NOTE: Active, wet lesions cannot be covered to allow participation

Tinea aka Ringworm

Ringwormis a fungal infection that can be seen anywhere but most commonly affects the skin on the body (tinea corporis), the scalp (tinea capitis), the feet (tinea pedis, or ‘athlete’s foot’), or the groin (tinea cruris, or ‘jock itch’).

Signs and Symptoms:

• Tinea corporis lesion: Round, reddened, scaly plaque with raised borders
• Tinea capitis lesion: Round, gray scaly patches accompanied by mild hair loss
• Tinea pedis lesion: Common in the toe webs, skin is usually complemented by thick scaling
• Though normally circular in shape, the lesion may present with a more irregularly shaped border in athletes

Return to Play Guidelines:

• Oral or topical fungicide medicine as prescribed by physician for at least 72 hours (3 days) for tinea corporis or 14 days for tinea capitis (on the scalp).
• Once lesion is considered to no longer be contagious, it must be adequately covered (occlusive dressing) when the athlete is cleared to return to activity

Molluscum Contagiosum

Molluscum Contagiosum is a viral infection transmitted by skin-to-skin contact.

Signs and Symptoms:

• Lesion: fleshed-colored to light-pink pearly papules with a dent or depression in the middle. Often, a small predominantly itchy patch of eczema can develop around the lesions a month or more after development

Return to Play Guidelines:

Lesions must be curetted (scraped out) by a physician and subsequently covered for competition.

Impetigo

Impetigo is a superficial bacterial infection most commonly found on the face, neck, and upper extremities. It is highly contagious and MAY NOT be covered for competition without treatment.

Signs and Symptoms:

• Lesions: begins as a thin-walled vesicle that ruptures to expose a raw surface covered in a yellowish-brown or honey-colored crust. In the early stages it may also present as a superficial blister that ruptures easily

Return to Play Guidelines:

• No new skin lesions for at least 48 hours (2 days)
• Completion of a 72 hour (3 day) course of directed antibiotic therapy
• No further drainage from the wound
• Active lesions MAY NOT be covered for competition

Folliculitis, Furuncles, Carbuncles

Folliculitis is an infection of the hair follicles that appears in areas of high friction and perspiration and is caused by a bacteria (most commonly Staphylococcus aureus). Furuncles (boils) and carbuncles (larger boils) are complications of this infection. Active infections MAY NOT be covered for competition.

Signs and Symptoms:

• Folliculitis lesion: red or white bumps at the base of the hair follicles, especially in areas that have been shaved, taped, or abraded
• Furuncle lesion: tender, red, nodular swelling
• Carbuncle lesion: when multiple furuncles join, a mass of pus filled tissue develops with localized redness and swelling. A fever also may be preset.

Return to Play Guidelines:

• Completion of 72 hour (3 day) course of antibiotic therapy
• No further drainage from the wound
• No new skin lesions for at least 48 hours (2 days). Any remaining dry, scabbed lesions should be covered during competition

MRSA aka Methicillin-Resistant Staphylococcus Aureus

MRSA aka Methicillin-Resistant Staphylococcus Aureus is a severe bacterial infection that common antibiotics cannot treat. MRSA lesions often can confused as spider bites. It is a highly contagious and potentially dangerous infection. Active lesions MAY NOT be covered for competition

Signs and Symptoms:

• Lesion: Initially, lesions can look very similar to folliculitis/furuncle/carbuncle infections. Develops quickly from small pustules into larger pustules or abscesses with swelling, redness, and possibly black markings
• Other symptoms may include systemic infections symptoms such as fever, fatigue, etc.

Return to Play Guidelines:

• Completion of 72-hour (3 day) course of directed antibiotic therapy.
• No further drainage from the wound
• No new skin lesions for at least 48 hours (2 days)
• Inactive, dry, healing lesions need to be covered for competition

Prevention:

• Perform a daily full-body skin check and report any suspicious lesions to your Athletic Trainer or physician as soon as it appears.
• Have all game and practice gear laundered daily.
• Follow good personal hygiene practices:
  • SHOWER with antimicrobial soap immediately after practices and games and wash hands frequently.
  • AVOID sharing towels, razors, athletic equipment, water bottles, and hair clippers.
  • AVOID body shaving.
  • AVOID entering common whirlpools or tubs if skin lesions are present.

REPORT IT!

The sooner you report it, the sooner you get treatment and the sooner you return to play.

These diseases are all highly contagious. Hiding or failing to notice them could have serious consequences, such as…

• The disease may be passed to your teammates and/or opponents.
• If not treated, some of these diseases can lead to potentially dangerous complications –and thus more time out of practice and competition.

MRSA Photo Courtesy of Bruno Coignard, M.D., Jeff Hageman, M.H.S and the CDC

Tinea (Ringworm) and Molluscum Contagiosum Photos Courtesy of Dermatology at Nationwide Children’s Hospital

Herpetic Lesions and Impetigo Photos Courtesy of Sports Medicine at Nationwide Children’s Hospital

Nationwide Children’s Hospital Sports Medicine specializes in diagnosing and treating sports-related injuries in youth, adolescent, and collegiate athletes.  Services are available in multiple locations throughout central Ohio.  To make an appointment, call 614-355-6000 or visit our website at www.nationwidechildrens.org/sports-medicine. 

Dermatology Advice and Guidance with a Photo

Why have I been referred to the Dermatology Advice and Guidance with a photo service?

GPs diagnose and treat some skin problems themselves. However on occasion they may wish to refer your skin problem to benefit from a skin specialist (consultant) opinion. This service utilises modern technology to obtain a rapid diagnosis and treatment plan for your skin problem without you having to attend a hospital. 

What does Dermatology Advice and Guidance with a photo mean?

Dermatology Advice and Guidance with a photo involves using a camera to take high quality digital pictures of your skin.

These images are then sent electronically, with further information contained in the referral letter, to a skin specialist (Dermatology Consultant). The Dermatology consultant will diagnose your skin problem and provide recommendations on any treatment required. This service enables you to be seen quicker and at a place closer to your home. 

What happens?

Your GP will determine from the consultation if a specialist dermatology opinion is required. Photos will then be relayed (using a secure information system) to a specialist skin consultant.

The consultant will then make a diagnosis and send this to your GP within five working days outlining a recommendation to:

• Make clear if the condition needs to be treated
• How the condition should be treated
• What kind of medications can be used 

If your condition requires face to face assessment or you do not wish to have your photo taken, your GP will refer you to the hospital outpatient service. You will be provided with details to book the hospital appointment. 

Your GP will continue to manage your skin problem using the advice received from the consultant and can seek further advice from the consultant if it is needed.

If the consultant feels your condition is urgent, he/she will refer you directly to a hospital of your choice. It is important to note that at any point along this pathway, if your condition is suspected to be urgent or a possible cancer, you will be referred as using through the urgent cancer referral pathway (2 week cancer pathway) 

Instructions to take photos

Camera set-up

• Use an ‘automatic setting’ on camera
• Images must be in focus and taken in natural light wherever possible
• Image resolution should not be greater than 3 megapixels and the file size less than 1Mb. 

• Select a ‘small’ or ‘medium’ file size if emailing photos from your smart phone into your GP practice  

Taking high quality images:

• Take a long shot to show the extent and close-up image (macro focus) to show detail.
• Lesions should have a ruler next to them to show size if possible.
• If there are several lesions on a patients back for example, take a long shot of the whole back, and then close up shots of the suspicious lesions. If you work from head to foot, and right to left with the camera, it will make it easier to remember which lesion was which.
• Blurred images will not accepted.
• With any transfer over the internet, there is a potential risk relating to the delay of care and transfer of patient identifiable information. Contact your GP practice if you feel there is a delay. 

Ensure that the photo shows the detail of the area involved with the surrounding normal skin. 

Where possible, use a ruler or a coin to show perspective:

With the scalp, take a photo of the head and also a close up of the area involved:

For more tips on how to take clear, high quality photos of your skin condition, please refer to the Photo taking guide which can be found in the download section.

The link between skin and psychology

When Rick Fried, MD, PhD, gave a talk at a dermatology conference seven years ago on the relationship between psychological and dermatological problems, at least one dermatologist in the audience was skeptical about the mind/body connection. Then another dermatologist stepped to Fried’s defense, telling her colleague that before he attacked Fried he should at least make sure his zipper was up. The skeptic’s fly wasn’t really down, but his deep blush vividly illustrated the impact that emotions have on the body’s largest organ — the skin.

“How amazing is it that a simple cognition — ‘I said or did something foolish’ — can cause virtually every blood vessel in the skin to instantaneously open up, causing a blush or flush?” asks Fried, a psychologist turned dermatologist who is the clinical director of Yardley Dermatology Associates and Yardley Clinical Research Associates in Yardley, Pennsylvania. “That’s pretty amazing evidence that the mind and body are linked.”

These days, dermatologists are much more accepting of the field now known as psychodermatology, and psychologists are getting more involved in helping dermatology patients. They’re investigating the role that stress and other psychological issues play in acne, psoriasis, eczema, itching, hives and other skin problems. They’re treating the social anxiety, depression and other psychological issues that can arise when people have skin conditions. They’re also developing interventions, whether to help dermatology patients deal with psychological issues or to help people avoid melanoma and other skin problems in the first place.

Minding the skin

While psychodermatology is a well-established field in Europe, it has been slower to catch on in the United States, according to a history of the movement on the Association for Psychoneurocutaneous Medicine of North America (APMNA) website. There are just a few psychodermatology clinics in the country, the association reports. Most medical school curricula don’t include psychodermatology material. And there are few researchers and limited research funding in this area.

What’s more, the field consists primarily of dermatologists and psychiatrists, says Kristina G. Gorbatenko-Roth, PhD, a psychology professor at the University of Wisconsin–Stout. She became interested in psychodermatology when she developed the hair loss condition alopecia areata and discovered that depression, anxiety and other psychological issues were common among participants posting in an alopecia-related Internet chat room.

The APMNA is eager for psychologists to get involved in the field, says Gorbatenko-Roth, who is working with two European psychologists to develop training materials for those interested in developing a clinical competency in psychodermatology.

“The skin is the most noticeable part of our body that could be impacted by psychological factors, yet very few psychologists are studying it,” she says. “It’s classic health psychology, just in a different area.”

Psychologists have roles to play in treating all three types of psychodermatology disorders, says Gorbatenko-Roth. The three types are:

• Skin problems affected by stress or other emotional states.
• Psychological problems caused by disfiguring skin disorders.
• Psychiatric disorders that manifest themselves via the skin, such as delusional parasitosis.

“Psychologists’ service provision skills are highly applicable and relevant,” she says. “Coupling this with the lack of psychologists with training in psychodermatology, and the growth potential for psychologists becomes more apparent.”

Rick Fried is one of the few U.S. clinicians specializing in psychodermatology. Skin problems can be extremely distressing, he says. For one, flare-ups of psoriasis, eczema, acne and other conditions can be unpredictable. Unlike hypertension, diabetes or other health problems, skin problems are usually obvious to onlookers. Plus, patients may have psychological reactions that seem out of proportion to their actual skin conditions.

“We can never presume that the so-called objective severity of a dermatological disorder correlates with the psychological impact,” says Fried. “I’ve see people who have nodulocystic acne who aren’t happy but really aren’t psychologically distraught; I’ve also seen patients with one zit on their chin who have attempted suicide.”

Having a skin problem can prompt intense distress. In a 2014 National Rosacea Society survey of 1,675 patients with rosacea — a condition that causes facial redness and related symptoms — 90 percent of respondents reported lowered self-esteem and self-confidence, 54 percent reported anxiety and helplessness, and 43 percent reported depression, for example. More than half said they avoided face-to-face contact.

In a vicious circle, stress, depression and other kinds of psychological problems can exacerbate the skin problems. “The common dermatological issues that have been documented to be made worse by stress include acne, rosacea, psoriasis, itching, eczema, pain and hives, just to name a few,” says Fried.

Fortunately, he says, treating psychological problems can also improve skin problems.

In a paper published in 2013 in Seminars in Cutaneous Medicine and Surgery, Fried reviewed the evidence for nonpharmacological management of psychodermatalogical conditions. Proven interventions — typically used as complements to traditional dermatological approaches — include hypnosis, support groups, biofeedback, meditation, guided imagery, progressive muscle relaxation, cognitive-behavioral therapy and other forms of psychotherapy.

The key, says Fried, is to give patients a sense of control over their conditions and their reactions to them. Cognitive-behavioral therapy, for example, can help patients manage stress and stop catastrophizing, such as saying they’ll kill themselves if their psoriasis acts up on an important day.

Boston psychologist Ted A. Grossbart, PhD, a private practitioner who specializes in psychodermatology, uses a variety of therapies to help people with skin conditions, including imaging and meditation. Hypnosis can be especially helpful, he says. The key is to help patients focus on an image associated with the desired change, whether it’s warmer, cooler, dryer, moister or less itchy skin, says Grossbart, who is also an assistant professor of psychology at Harvard Medical School. A patient with eczema, for instance, might zero in on the image of a tropical rainforest to counteract the drying the condition brings.

“Often, people are doing what I call inadvertent negative hypnosis anyway,” says Grossbart. “If that very same mechanism can get used in a focused way and in a proper dimension, the results can be quite dramatic.”

These kinds of interventions don’t just help patients’ distress, says Fried. They can also improve patients’ skin and their responsiveness to treatment. In one study Fried cites in his literature review, for example, patients who listened to a mindfulness meditation program while undergoing phototherapy treatment for psoriasis needed 40 percent less exposure to ultraviolet light than others.

Fried refers his patients who need more intensive psychological assistance to psychologists, whom he calls “skin-emotion specialists” as a way of reducing stigma and overcoming patients’ reluctance to seek mental health care.

In some cases, adds Grossbart, skin problems are the outward manifestation of an underlying mental disorder.

Take skin picking, for example. “Sometimes people would have perfect skin if they would just leave it alone,” says Grossbart. “But they can’t.” Their picking may be a form of addiction, a symptom of attention-deficit disorder or the outward sign of obsessive-compulsive disorder, all of which require different treatment approaches. “You’ve got to do detective work first,” says Grossbart.

Preventing problems

Psychologists are also helping prevent dermatological problems from developing.

Kasey Lynn Morris is investigating the best ways to prevent melanoma and other problems caused by excessive tanning, for instance.

“Tanning is one of those areas where even though people know how bad it is for them, they still do it,” says Morris, a graduate student in social psychology at the University of South Florida.

Research has shown that reminding people of tanning’s potentially fatal consequences can help curb people’s desire to tan, at least temporarily. But as thoughts of death slide into the unconsciousness, which happens very quickly, people’s desire to tan actually increases if being tan is relevant to self-esteem, as is often the case for women, says Morris.

“The reason is that non-conscious thoughts of death motivate a desire to maintain self-esteem,” Morris explains. “If a person’s appearance is relevant to their self-esteem — and being tan is a part of that cultural appearance ideal — then non-conscious thoughts of death will motivate a desire to uphold that ideal by tanning one’s skin.”

Adding an appearance-related element to the intervention can “re-route” that self-esteem, Morris and colleagues found in two experiments described in a 2014 paper published in Psychology and Health. In the experiments, the researchers exposed women not just to a reminder of mortality via a funeral scene depicting a woman sunbathing on a beach but also to UV-filtered photos of their own skin, a technique that reveals sun damage. “If you’ve ever seen a UV-filter photo of yourself, you know you look terrible,” says Morris. When the death- and appearance-related interventions were combined, they decreased participants’ intentions to tan and increased the amount of sunscreen they took from the researchers.

“It relies on the assumption that people value their appearance — and research suggests the majority of women do — and the knowledge that unconscious thoughts of death motivate a desire to maintain self-esteem,” says Morris. “If you prime thoughts of death, followed by a delay to give it time to no longer be conscious and then remind people how much sun damage can hurt their appearance, they are subsequently going to try to boost their self-esteem by maintaining their appearance through using sun protection.”

Now Morris and her team are exploring whether participants follow through on their intentions in everyday life.

Other psychologists are working on interventions designed to prevent psychological problems from developing among dermatology patients.

Heidi Williamson, DHealth, Psychol, for example, has worked with young people to develop an online interactive intervention called YP Face IT. It’s designed for youth ages 12 to 17 who are distressed because of conditions or injuries affecting their appearance, including skin issues such as acne, psoriasis, burns or scars. The seven-week program teaches kids coping strategies and social skills.

“What young people fear most is being judged negatively for their appearance,” says Williamson, a senior research fellow at the Centre for Appearance Research at King’s College London. And anticipating negative judgments can make young people anxious and self-conscious, which can mean that young people lose their social skills or fail to develop them in the first place.

YP Face IT teaches users how to overcome negative thoughts about their appearance as well as how to handle social situations, such as answering questions about their conditions, coping with teasing and bullying and making the most of their body language and verbal skills. Participants can also find support through a discussion forum. Throughout the program, a psychologist or other health-care professional monitors users’ progress and can suggest more intensive help if necessary.

While Williamson and her colleagues are still evaluating YP Face IT, preliminary results suggest that it decreases social anxiety scores and increases assertiveness and social skills.

For Gorbatenko-Roth, all this activity by psychologists is a welcome change.

“Dermatologists and other health-care providers are out there doing the best they can for patients, but they’re frustrated, because they see their patients’ emotional distress but typically have neither the time nor the tools to fully address it,” she says, urging psychologists to attend the APMNA’s next annual conference in San Francisco in March. “This is a great role for psychologists.”

Rebecca A. Clay is a journalist in Washington, D.C.

Skin Problems in Children

Do children get skin problems?

Children’s skin problems span nearly two decades from birth through adolescence. Several common pediatric skin conditions will be discussed including: diaper dermatitis, atopic dermatitis, warts, and acne.

What is diaper dermatitis?

Diaper dermatitis, or diaper rash as it is more commonly known, is not a diagnosis but rather a category of skin conditions affecting the diaper area. There are four types of diaper dermatitis, including:

• Irritant contact dermatitis.
• Overgrowth of yeast (Candida albicans).
• Allergic contact dermatitis.
• Inflammatory skin conditions such as seborrheic dermatitis.

The most common type of diaper dermatitis is irritant contact dermatitis, associated with skin exposure to either urine or feces (or both) for a long period of time. Irritant contact dermatitis usually appears as bright red, sometimes slightly swollen, or even blister-like patches in the diaper area. Prolonged irritant contact dermatitis can increase the risk of infection in the affected area.

The primary treatment and prevention of irritant contact dermatitis includes frequent diaper changes to prevent extended contact with moisture and barrier creams and ointments, most commonly containing zinc oxide. A mild topical steroid ointment or cream can also be very helpful in more quickly reducing the inflammation.

The next most common type of diaper dermatitis is the overgrowth of yeast, most commonly Candida albicans. The warm, moist, and often irritated environment of the diaper makes the skin more prone to an overgrowth of yeast. This condition generally develops on top of irritant contact dermatitis.

Usually, it appears as bright red bumps, patches, and sometimes pus-bumps that are found on the skin and in its folds. The condition can be treated with an over-the-counter topical antifungal cream such as clotrimazole (Mycelex®), mycostatin (Nystatin®), or with a prescription medication. A barrier cream, often containing zinc oxide, is also recommended to treat and prevent this skin condition. If irritant contact dermatitis is also present, sometimes an additional mild topical steroid is prescribed. If this condition is only treated with topical steroids, the yeast infection can worsen.

Rarely, allergic contact dermatitis will occur. This condition is usually associated with a component of the diaper itself such as elastic or adhesive, or fragrance or preservatives in baby wipes. Symptoms include redness and swelling with itchiness that continues to recur in the same area such as the near the diaper’s adhesive tape or around the leg where there is elastic in the diaper.

Treatment of allergic contact dermatitis is very similar to the treatment of irritant contact dermatitis: barrier creams and ointments, most commonly containing zinc oxide, or mild topical steroid ointment if necessary.

To prevent allergic contact dermatitis, you need to identify the material that is causing the problem and avoid it.

Seborrheic dermatitis, commonly known as cradle cap in infants and dandruff in older children and adults, can also be the cause of diaper dermatitis. This condition also affects other areas of the body such as the scalp, face, neck, as well as the skin folds. Treatment includes topical antifungal creams and often the careful use of mild topical steroid.

Topical steroids require very careful use, especially in the diaper area to prevent potential side effects such as thinning of the skin and stretch marks. These effects can be prevented by using low potency topical steroids, such as hydrocortisone 1 to 2.5 percent, and applying topical steroids sparingly to the affected areas only twice daily as needed for no longer than two weeks at a time.

What is atopic dermatitis?

Atopic dermatitis, or eczema, is a skin condition that can occur at any time in life. It often starts early in childhood and may not diminish until early adulthood. Over half of infants with atopic dermatitis grow out of the condition by age 2, though many adults will continue to have sensitive skin and some continue to flare throughout life.

Atopic dermatitis is a chronic condition, which means that it cannot be cured but it can be treated and controlled with proper guidance from a physician.

The condition is most common in families who have a history of seasonal allergies and asthma. Though food allergies are more common in children with atopic dermatitis, foods are rarely the cause of atopic dermatitis flares.

Atopic dermatitis can get worse when the skin comes into contact with irritating substances such as saliva; harsh soaps; and scratchy, tight fitting clothing. Friction can also contribute, especially when affected children start to crawl.

What are the symptoms of atopic dermatitis?

In infants:

• Red, very itchy dry patches of skin.
• Rash on the cheeks that often begins at 2 to 6 months of age.
• Rash oozes when scratched.

Symptoms can become worse if the child scratches the rash and openings in the skin can become infected.

In adolescence and early adulthood:

• Red scaly rash on creases of hands, elbows, wrists and knees and sometimes on the feet, ankles and neck.
• Thickened skin markings.
• Skin rash may bleed and crust after scratching.

How is atopic dermatitis treated?

Gentle skin care with mild soap, short daily baths and lots of moisturizer is the best way to prevent atopic dermatitis flares. Moisturizers that contain ceramides help to repair the skin barrier and are especially helpful. During flares, treatment is aimed at reducing extreme itching and inflammation in the skin and treating infection if it develops. It includes topical steroid creams and oral antihistamines. Treatment will depend on the age of the child and the severity of the symptoms. Follow your healthcare provider’s instructions for using the medications.

To help your child, you can also:

• Avoid long, hot baths, which can dry the skin. Short, daily baths in lukewarm water are recommended
• Apply moisturizing cream with ceramides right after bathing or showering This step will help trap moisture in the skin.
• Use moisturizers often, at least twice daily. Thick creams work better than lotions.
• Keep the room temperature as regular as possible. Changes in room temperature and humidity can dry the skin.
• Keep your child dressed in cotton. Wool, silk and man-made fabrics such as polyester can irritate the skin.
• Use mild laundry soap without fragrance and dyes and make sure that clothes are well rinsed.
• Watch for skin infections, which are more likely with eczema. Contact your healthcare provider if you notice an infection.
• Avoid rubbing or scratching the rash.

If atopic dermatitis is severe, oral medications may need to be used. If open wounds result from excessive itching, a topical antibiotic (mupirocin, Bactroban®) may be used. Occasionally, an oral antibiotic is necessary to treat infection. If these treatment methods are not effective, alternative therapy such as phototherapy (light therapy) may be recommended for older children.

What are warts?

Warts result from an infection with a virus, and are common in children of all ages. Warts commonly appear as hard bumps on fingers, hands and feet.

Molluscum contagiosum is a similar type of infection caused by a different virus. It causes pink or skin- colored smooth bumps that can appear anywhere on the body. They are not harmful and will generally go away on their own in a couple of years, but treatment can help them go away more quickly.

What causes warts?

Common and flat warts are caused by the human papilloma virus (HPV), while molluscum contagiosum warts are caused by a pox virus. Warts usually spread through direct contact. It is also possible to pick up the virus in moist environments such as in showers and locker rooms.

How are warts treated?

Unfortunately there are no antiviral treatments that actually target the virus itself. Instead, the treatment available is targeted against the skin in which the virus is living.

Over-the-counter treatments include liquid and film medications containing salicylic acid, which softens the abnormal skin cells and dissolves them. Higher percentages of salicylic acid (20 to 40 percent) are most effective.

Over-the-counter wart treatments are very effective to treat warts, but must be used daily. First, soak the wart in warm water to soften the skin. Then gently file thickened skin with a disposable emory board. Throw away the used portion so you do not re-infect the skin. Apply the medicine and cover with a bandage (replace the bandage if it gets wet). Repeat daily. Warts usually require weeks to months of treatment to completely resolve.

In the dermatologist’s office, wart treatment will depend on the age of the child, the number and location of the warts, and the patient’s and parent’s decision. Wart treatment options by the doctor include:

• Freezing the wart with liquid nitrogen (cryotherapy).
• Destroying the wart with chemicals (trichloroacetic acid or cantharidin preparations).
• Burning the wart off with electricity or a laser (such as a flash lamp or CO2 lasers).
• Injecting the wart with yeast preparations to stimulate the immune system.
• Oral cimetidine (Tagamet®) may be prescribed along with one of the methods above. It has been shown to boost the immune system to better mount an immune response to the wart virus infection. Cimetidine is usually used for a trial two to three months.
• Imiquimod (Aldara®) is a cream that may be prescribed to help your body’s immune system fight warts.

Molluscum contagiosum treatment methods by the doctor include:

• Topical tretinoin (Retin-A®) or over-the-counter Differin® gel.
• Destroying the wart with chemicals (trichloroacetic acid or cantharidin preparations).
• Freezing the wart with liquid nitrogen (cryotherapy).
• Scraping the wart off (curettage).

It is important to mention that these wart treatments often need to be repeated every 3 to 4 weeks until the wart is gone. Individual molluscum lesions can usually be cured in fewer treatments.

All of these treatment methods may cause scarring and/or blisters so it is important to practice good wound care throughout the healing process.

How can warts be prevented?

Certain precautions can be taken to reduce the chance of getting warts, including:

• Wearing rubber sandals or shoes in public shower areas or swimming pools.
• Avoiding direct physical contact with those who have visible warts.
• Practicing good hygiene.

What is acne?

Acne is one of the most common skin problems. Acne is most common during the hormonal surge of adolescence, but also affects 20 percent of adults. Though it usually improves with age, adolescent acne usually benefits from treatment.

What causes acne?

Poor hygiene, poor diet and stress can aggravate acne but do not cause it.

Acne starts when tiny hair follicles or pores become plugged with oily secretions (sebum) from the skin’s sebaceous glands as well as keratin (a skin protein). This blockage is known as a black head or a white head. These plugged follicles can develop into swollen, red, tender pus bumps, or larger cysts or nodules that can cause temporary or permanent scarring.

What products should be avoided to reduce acne?

If the acne is predominantly around the hairline, it may be associated with hair products such as conditioner, hair gels, hair mousse, oils, and grease. This type of acne can be improved by limiting hair products and pulling the hair away from the face.

Comedogenic (pore-blocking) moisturizer or cosmetics should be avoided. Try switching to a water based non-comedogenic moisturizer and/or cosmetics.

Skim milk is the only food that has been shown to be associated with acne.

How can acne be treated?

Mild acne may improve with over-the-counter cleansers containing either benzoyl peroxide or a low percentage of salicylic acid or with Differin® gel, which is a mild vitamin A cream (retinoid) now available over the counter. If the use of these products does not improve the acne within 8 to 12 weeks, it may be necessary to see a dermatologist. It is important not to wait too long before seeking treatment to avoid unnecessary scarring.

Prescribed acne treatments will depend on the age of the patient, skin type, and most importantly, the severity of the acne. Topical retinoids (Retin-A®, Differin®) are a mainstay of treatment and help prevent the blocked pores that develop into acne lesions. The topical regimen often includes an acne wash containing benzoyl peroxide and sometimes a topical antibiotic. Switching to a gentle non-soap cleanser is helpful if the other prescribed acne treatments are causing excessive dryness or mild irritation.

Depending upon the patient’s age and the type of acne, an oral antibiotic (minocycline, doxycycline or erythromycin) may be beneficial.

It is important for the patient to follow the prescribed treatment for at least 8 to 12 weeks before considering changing therapy. During a follow-up visit with the dermatologist, a re-evaluation can determine whether or not the treatment plan needs to be modified.

Other medications that have been helpful are oral birth control pills for females, especially when they report acne flare-ups around the menstrual period. If an individual has severe scarring acne, or if aggressive standard therapy does not improve their acne, an oral retinoid (Accutane®) may be necessary. If this is dosed and monitored appropriately, it is a safe option for treatment and the only treatment that can lead to a permanent cure.

Skin Diseases are Common in Older Adults > Health in Aging Blog > Health in Aging

Journal of the American Geriatrics Society Research Summary

As we age, our skin changes in ways that can make it more prone to disease. That’s because older skin is less oily, less elastic, and thinner. It bruises easily and can take a long time to heal when cut.

Although skin disorders are common in older adults, few studies have examined the connection between aging and skin disease. The studies we do have are mostly collected from specific groups of older adults, such as nursing home residents or those who have been treated in hospitals.

However, we do know that two studies of health records for large groups of older adults show that the most common skin diseases in older people are eczema, skin infections, and pruritus (severely dry and itchy skin). Recently, a research team designed a study to learn more about how common skin diseases are in adults aged 70 and older. They published their study in the Journal of the American Geriatrics Society.

The scientists used information taken from The Northern Finland Birth Cohort 1966, a research program conducted in northern Finland (Oulu and Lapland). Researchers from that study followed 12,058 participants regularly since their birth. The parents of these study participants also served as a subset of the study and participated in separate skin examinations to learn more about skin diseases in older adults

By the end of the skin study, researchers sent a health questionnaire to the parents. Of these, 46 percent responded and some 1200 people who lived in Oulu were invited to participate in the clinical examination. Researchers gave whole-body skin examinations to 552 people.

All areas of the skin including the nails, hair, and scalp were examined during a 20-minute visit. All skin diseases which could be seen during the visit were recorded. Researchers counted all the skin tumors and then examined them more closely with a special instrument called a dermatoscope.

The researchers learned that nearly 76 percent of the participants had at least one skin disease that required treatment or follow-up. Over one-third of the participants had three or more skin diseases, with fungal skin infections being the most common. The researchers reported that almost half the participants had tinea pedis (athlete’s foot) and 30 percent had onychomycosis (nail fungus).

Other skin diseases found during the examinations included:

• Rosacea, a condition that causes people to blush or flush easily, found in 25 percent of participants.
• Asteatotic eczema, characterized by dry, itchy, and cracked skin, found in 21 percent.
• Seborrheic dermatitis, which causes dandruff, found in 10 percent.
• Nummular eczema, which features coin-shaped itchy, reddened patches, found in 9 percent.
• Previously undiagnosed actinic keratosis, a precancerous skin lesion, found in 22 percent of the population.

Overall, benign (non-cancerous) skin tumors were the most common skin findings in this study.

To the best of their knowledge, the researchers said that this is the largest study to date in the field of geriatric dermatology to be based on a whole-body skin examination.

The researchers concluded that this study provides new data about skin diseases in older adults. “We learned that dermatological disorders are extremely common in older individuals, and this should be taken into account by physicians treating geriatric patients,” said the researchers. “A whole-body clinical skin examination may reveal hidden skin diseases and can ensure timely diagnoses and appropriate treatment.”

This summary is from “The high prevalence of skin diseases in subjects aged over 70 years.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are  Suvi-Päivikki Sinikumpu MD, PhD; Jari Jokelainen, MSc; Anna K. Haarala MD; Maija-Helena Keränen MD; Sirkka Keinänen-Kiukaanniemi MD, PhDd; and Laura Huilaja MD, PhD.

Pediatric Dermatology

Currently, there are over twenty thousand forms of skin diseases in the world, almost half of which are dermatoses. In childhood, one of the main places is occupied by allergic skin diseases or the so-called allergic dermatoses, the frequency of which, according to various sources, ranges from 50 to 80% and is steadily increasing.

Types of skin diseases in children

The most common dermatological diseases characteristic of childhood can be divided into eight main groups.
The first group includes dystrophic skin diseases. As a rule, these are hereditary diseases, an example of which is acrodermatitis and epidermolysis bullosa.
The second group includes bacterial skin diseases (pyoderma). These include staphyloderma, streptoderma, pemphigus and omphalitis. Especially often in children’s groups they meet impetigo (one of the forms of streptoderma).
The third group is represented by viral skin diseases.Most often it is a herpes infection, caused by viruses of two types of herpes simplex. Easily transmitted from child to child, contagious.
The fourth group includes allergic diseases. Atopic dermatitis is more common, manifested in increased skin sensitivity in case of contact with various allergens. Hives are also known to cause severe itching blisters.

The fifth group includes neoplasms on the skin, such as papillomas, warts, etc.e. In no case should you remove the appeared wart or birthmark yourself, this can only be done by a doctor, with the help of cauterization or cryodestruction.
The sixth group includes fungal skin diseases. The most common are trichophilia, favus, candidiasis, dermatozoonosis, microsporia, lichen.
The seventh group includes various nail lesions. This can occur both due to fungal infections and due to diseases of internal organs, metabolic disorders, lack of minerals and vitamins.
The eighth group , the last one is hair lesions. There are a lot of types of these diseases, for example, some children have alopecia (general baldness), others have hypertrichosis (the opposite situation is excessive hair growth of the trunk and limbs). Often there are acute purulent inflammations in the area of ​​the hair follicle and the hairy base, as well as the sebaceous glands and surrounding tissues. Pediculosis (nits, lice) is often recorded in children’s groups.

Symptoms and signs of skin diseases in children

Skin diseases in children differ from those in adults in their manifestations.The presence of a dermatological disease in a child is signaled by various rashes. They can appear in the form of spots and rashes, papules and bumps, nodules and blisters, pustules and vesicles, scales, abrasions, scars, ulcers, etc.

If a child detects certain symptoms of skin diseases, should immediately make an appointment with a pediatric dermatologist.
Before the first visit to the doctor, you do not need to use antiallergic and external medicines, as this will distort the picture of the disease!
Children’s dermatologist will make an accurate diagnosis and prescribe an individual therapy regimen for each child, as well as monitor the process of further treatment and rehabilitation!

90,000 Dermatologist told what skin problems COVID-19 provokes

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A dermatologist told what skin problems COVID-19 provokes

A dermatologist told what skin problems COVID-19 provokes – RIA Novosti, 01.24.2021

A dermatologist told what skin problems provoke -19

Coronavirus causes serious skin problems. Which, in an interview with radio Sputnik, said dermatologist, cosmetologist Stanislav Arkannikov. RIA Novosti, 24.01.2021

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