Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Most people who fall sick with COVID-19 will experience mild to moderate symptoms and recover without special treatment.

How it spreads

The virus that causes COVID-19 is mainly transmitted through droplets generated when an infected person coughs, sneezes, or exhales. Generally, these droplets are too heavy to hang in the air and quickly fall on floors or surfaces. You can be infected by breathing in the virus if you are within close proximity of someone who has COVID-19, or by touching a contaminated surface and then your eyes, nose or mouth.

To know more about COVID-19 and it’s associated clinical features, check out this link: https://www.who.int/emergencies/diseases/novel-coronavirus-2019

COVID-19 and Skin¹

COVID-19 has many effects on our skin, hair and nails. Some of the conditions are directly due to the disease and some of them are due to reduced immunity after the infection and in some situations, even because of the medicines taken for COVID-19. Expertise in recognising these signs could be an opportunity to improve diagnosis and management like the well-described association with loss of smell (anosmia) which prompts suspicion for SARS-CoV-2 infection. In an effort to have an extensive database of skin manifestations, health care workers around the globe have submitted data for possible cutaneous manifestations of confirmed or suspected cases of COVID-19.

The most common morphologies of skin rash were:

• Morbilliform (22%)
• Pernio-like (18%)
• Urticarial (16%)
• Macular erythema (13%)
• Vesicular (11%)
• Papulosquamous (9.9%)
• Retiform purpura (6.4%)

A minority of patients presented with multiple morphologies which included two or more patterns of the above in varying combinations.

When does it occur?

• After the symptoms – 64%
• During the symptoms – 15%
• Before the symptoms – 12%
• Asymptomatic – 9%

Lesions generally occurred after the symptoms subsided.

How long will it last?

Skin symptoms and affected body sites varied depending on the morphology. For example, the morbilliform rash was often associated with itching and involved the trunk, whereas pernio-like often caused pain/burning and involved the feet/hands. Retiform purpura was on the extremities and buttocks. The rashes lasted an average of 7 days (3-10 days). Pernio-like has a longer course, with an average of 14 days (8-24 days).

What should I do?

Do not worry if you have skin manifestations as they are generally not life-threatening. If you have developed a skin rash due to COVID-19, then it is important to follow the guidelines and remain in quarantine or the hospital and continue the isolation or treatment as suggested by your physician. That will depend on the severity of the infection and the symptoms of the infection. In addition, if the lesions are symptomatic and causing discomfort then you can consult a skin specialist near you.

Other Skin Manifestations

Herpes Zoster: It is a viral infection that affects the skin and nerves. They may occur after COVID-19 infection or in some cases even after vaccination. It is important to treat the condition early as that can help in full recovery and prevent long term nerve pain.

Other opportunistic infections: Many other fungal and other microbial infections may affect the skin due to reduced immunity during or after COVID-19 infection and sometimes, even due to the medicines taken for the infection.

Skin Necrosis: The patient often requires invasive mechanical ventilation which can cause pressure injury on the nose, cheeks and other parts of the face. Pressure injury on the buttocks due to prolonged hospitalisation is also common.

Skin peeling: This is usually seen in the palms and soles after the patient has recovered from COVID-19 and is also known as acral desquamation. The prevalence of hand dermatitis has also increased due to frequent use of alcohol-based sanitisers.

Hair shedding: Also known as telogen effluvium, it is a self-limiting condition that may occur within 6 months of infection and can take a few months to recover from.

Why does COVID-19 cause skin changes?

Although we have identified various dermatologic manifestations of COVID-19 to improve understanding of SARS-CoV-2 pathophysiology, the exact cause remains unknown. Previously, Suchonwanit et al proposed that cutaneous manifestations may present in 2 mechanistic patterns. Although this suggested dichotomy is a loose framework, it may prove a good starting point to consider our findings:

1. Clinical features similar to viral exanthems, an immune response to viral nucleotides
2. Cutaneous lesions are secondary to systemic consequences, especially vasculitis and thrombotic vasculopathy.

Conclusion

The study is limited by the constraints of a case series, which cannot accurately estimate the prevalence or incidence of these findings. The incidence of COVID-19 dermatologic manifestation remains unclear, with studies reporting 0.2% to 20%. There also remains the possibility of bias due to attribution error, given the reliance on providers’ judgment in entering data regarding whether findings were virus related, were from a medication, or were from other causes. Although providers were prompted for case updates, most reports represent a single snapshot, preventing full observation of dermatologic manifestations, disease complications, and follow-up testing.

However, the study goes a long way to show the patterns of skin manifestations due to COVID-19 and can help provide vital information to healthcare providers and patients.

For more information on skin and hair manifestations due to COVID-19, contact a certified dermatologist.

1. Journal of the American Academy of Dermatology – Volume 83 Issue 4 Pages 1118-1129 (October 2020) DOI: 10.1016/j.jaad.2020.06.1016

Lifestyle Changes and Diet

Lose weight

Losing weight, especially if you are overweight may reduce the condition’s severity. Losing weight may also make treatments more effective. It is also good for your overall health.

Regular Exercise

In continuation with the previous point, exercising regularly not only helps in controlling weight but it also improves the general health, reduces stress and releases anti-oxidants which helps to better control inflammation.

Eating a healthy diet

This includes eating a diet rich in omega-3 fatty acids, whole grains, and plants. Reduce your intake of saturated fats which are usually found in animal products like meats and dairy. Increase your intake of lean proteins that contain omega-3 fatty acids, such as walnuts, flax seeds, soybeans and fish.

Avoid trigger foods

Certain foods can cause inflammation and trigger an increase in psoriasis. If your condition is not under control with regular medicines then avoiding certain foods might improve symptoms. These foods include red meat, refined sugar, processed foods, dairy products.

Drink less alcohol

Alcohol consumption increases the chance of flare-ups. If you have a problem with your alcohol use, your doctor can help you form a treatment plan. Cutting down or completely stopping alcohol can help improve your psoriasis considerably.

Stop Smoking

Like alcohol, smoking has a direct link to psoriasis. It can trigger psoriasis as well as make the existing condition worse. Both active and passive smoking can lead to an increase and stopping it can help greatly with achieving disease control.

Consider taking vitamins

Some doctors prefer a vitamin-rich diet in pill form. Ask your doctor if you should be taking any vitamins as a supplement to your diet.

Stress

Stress is a well-established trigger for psoriasis. Learning to manage and cope with stress may help you reduce flare-ups and ease symptoms. Some methods to cope with stress better include meditation, journaling, music/dancing, breathing exercises and yoga

Emotional health

Today, there is a lot of awareness about mental and emotional health compared to a few years ago. People with psoriasis are more likely to experience depression and self-esteem issues. There may be a decrease in confidence when new spots appear. Talking with family members about how psoriasis affects you may be difficult. The constant cycle of the condition may be frustrating too.

All these emotional feelings are valid and natural. It is important to find a way for handling them which may include speaking with a professional or joining a group for people with psoriasis.

Learn more about living with psoriasis.

Avoiding of skin injury

During the unstable stage of the disease, psoriasis is known to increase in the areas of skin injury. This includes any accidental injury as well as self-inflicted micro-injuries like itching or scratching your skin. Combing your hair with toothed combs can also trigger a similar reaction on your scalp so use the hands to set your hair or use a soft brush. Similarly, working with vibrating machines or other appliances at work can trigger psoriatic arthritis so these triggers must be avoided.

Moisturise your skin regularly

Moisturising the skin regularly with a good moisturiser can help to maintain the barrier function of the skin by preventing water loss and helps to prevent dry skin and also soothes the skin cells. Regularly applying moisturiser helps in better psoriasis control.

Use a skin-friendly soap

The pH of healthy skin is between 4.5 and 5.5. Traditional soaps generally have a pH of 9, which is far too alkaline. Dove is a good soap at a 7, which is neutral. Some of the newer syndet bars are having a skin-friendly pH of 5.5 which is even better for the skin as it will help in maintaining the natural pH after bath and help to maintain the skin barrier function.

Avoid certain medicines

Psoriasis is known to be triggered or flared-up by certain medications e.g. Beta Blockers, Anti-malarials etc. To know more, consult your doctor and find out if there is any medicine which you should be avoiding.

Treat joint pain early

Around 30% of people with psoriasis may develop psoriatic arthritis according to the recent clinical guidelines from the AAD and the NPF.

It often begins as mild pain, swelling or stiffness and is sometimes ignored. That can lead to severe discomfort and disability in the future so consult your doctor if you have any signs or symptoms involving the joint.

Consult your skin specialist

Psoriasis occurs in cycles and there can be periods of remission. However, whenever there is a flare-up of the disease, you should consult your skin specialist. Recent research has shown that prompt and regular management of psoriasis reduces the chance of metabolic syndrome, cardiac disease, diabetes, depression and other systemic disorders.

How do dermatologists control psoriasis?

Psoriasis is often a lifelong condition. You should always discuss all the symptoms you are facing so that the doctor can help you in a better way. Dermatologists recommend the following:

• Use psoriasis friendly skincare.
• Find and avoid your psoriasis triggers.
• Treat psoriasis as needed.

Treatment Options

Luckily, there are many treatments. Some slow the growth of new skin cells and others relieve itching and dry skin. Your doctor will select a treatment plan that is right for you based on the size of your rash, where it is on your body, your age, your overall health, and other things. Common treatments include:

• Moisturizers for dry skin.
• Coal tar (a common treatment for scalp psoriasis).
• Vitamin D creams.
• Retinoid creams.
• Steroid creams.

Treatments for moderate to severe psoriasis include:

• Light therapy. A doctor shines ultraviolet light on your skin to slow the growth of skin cells. PUVA is a treatment that combines a medicine called psoralen with a special form of ultraviolet light.
• Methotrexate: This drug can cause bone marrow and liver disease as well as lung problems, so it’s only for serious cases. Doctors closely watch patients. You will have to get lab tests, perhaps a chest X-ray, and possibly a liver biopsy.
• Retinoids: These capsules, creams and gels are a class of drugs related to vitamin A. They’re not recommended for women who are pregnant or planning to have children but it can be effective in certain types of psoriasis.
• Cyclosporine: This drug, made to suppress the immune system, may be taken for serious cases that do not respond to other treatments. It can damage the kidneys and raise blood pressure, so your doctor will closely watch your health while you take it.
• Biologic treatments: These work by blocking the body’s immune system (which is overactive in psoriasis) to better control the inflammation from psoriasis. Biologic medications include adalimumab, brodalumab, certolizumab pegol, etanercept), guselkumab, infliximab, ixekizumab, risankizumab-rzaa, secukinumab, tildrakizumab and ustekinumab.
• Apremilast: It is a new kind of drug for long-term inflammatory diseases like psoriasis and psoriatic arthritis. It’s a pill that blocks a specific enzyme, which helps to slow other reactions that lead to inflammation.