The 2020 SARS-CoV-2 pandemic has presented an urgent challenge for medical professionals and scientists to not only care for the very ill with COVID-19 infection, but to appreciate and document the myriad manifestations of the disease. Dermatologists have similarly been challenged.

It was noted early in the COVID pandemic that skin manifestations were an important consideration in its diagnosis and management. As with many aspects of COVID-19, the exact nature of the dermatologic findings are still being investigated and defined. However, it is now generally accepted that there are some specific associated skin findings.

Both vasculopathic and reactive eruptions have been recognized. Pernio-like lesions, also known as “COVID toes,” are chilblain-like lesions that are typically seen in younger, healthy individuals who have experienced mild disease. Lesions appear as tender, itchy, or asymptomatic erythematous papules on the toes and less commonly on the fingers (Fig. 25-1). Viral DNA particles have been found by PCR in histopathology specimens, and the virus is believed to play a direct role in chilblain pathogenesis. Other vasculopathic manifestations include livedo reticularis (Fig. 25-2) and, in more severe cases, retiform purpura, which occurs in very ill, hospitalized patients and is thought to represent a thrombotic vasculopathy. Petechial and purpuric eruptions have also been reported (Fig. 25-3).

Numerous reactive dermatologic phenomena have also been recognized. Localized erythema, widespread macular and papular exanthems, and urticarial eruptions occur in symptomatic patients. The affected areas are commonly pruritic. A vesicular eruption has also been reported. This is typically monomorphic as opposed to varicella, where different lesion stages are seen. Papulosquamous eruptions (red and scaly), including those with a pityriasiform morphology, and vascular erythema-multiforme-like eruptions have also been noted.