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Cutaneous manifestations in patients with COVID-19 infection are being increasingly reported. Several patterns have been described since the initial report by Recalcati,1 including erythematous maculo-papular,1 urticarial,1,2 chickenpox-like,1,3 purpuric peri-flexural,4 transient livedo reticularis,5 and acro-ischemic or chilblain-like lesions.6,7 Herein we report the observation a new pattern with erythema multiforme-like lesions in 4 hospitalized patients with COVID-19 infection. All of them were women, and the mean age was 66.75 years (range 58 - 77). The mean time period between the onset of COVID-19 symptoms to the appearance of cutaneous lesions was 19.5 days (range 16 - 24). One patient developed the skin rash during hospitalization. The remaining 3 patients had been previously discharged after clinical, analytical and radiologic improvement, and negativization of COVID-19 PCR test. These 3 patients returned to the Emergency department consulting for skin rashes 6, 7 and 4 days after discharge, respectively. Laboratory tests at the time of skin lesions showed worsening of one or more parameters, compared to those at the time of discharge (CRP, D-dimer and lymphocyte count). However, none of the patients presented recurrence of clinical symptoms of COVID-19. Microbiological studies were performed in 2 patients, excluding other infectious diseases (Table 1). In all patients, skin lesions begun as erythematous papules in upper trunk, that progressively turned to erythemato-violaceous patches with a dusky center, and a pseudo-vesicle in the middle. Typical target lesions were observed in two patients. Lesions were markedly coalescing in the back, and then spread to the face and limbs within 1 week, without involvement of palms and soles (Figure 1). Three patient had their oral cavity examined, showing palatal macules and petechiae. Histological examination was similar in all patients, revealing a normal basket-weave stratum corneum, and mild to moderate spongiosis in epidermis. The dermis showed dilated vessels filled with neutrophils, extravasation of red blood cells, and lymphocytic perivascular and interstitial infiltrate. Basal vacuolar changes with interface dermatitis was observed in 1 patient, and lymphocytic exocytosis in another (Figure 2). All patients were treated with systemic corticosteroids with progressive resolution of the skin lesions within 2-3 weeks. We are facing challenging times in Dermatology. New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. Further studies are needed to evaluate whether these lesions are associated with the virus, the drug intake or any other conditions. Erythema multiforme (EM) is linked to infectious agents in 90% of the cases, while drug-associated EM is reported in less than 10% of cases. Herpes simplex virus (HSV) and Mycoplasma pneumoniae are the main agents, but other viruses have been reported, such as Adenovirus, Coxsackie, Parvovirus B19.8 We suggest that this EM-like or target-like exanthem might be another pattern of exanthem associated with COVID-19 infection. Recent articles also report targetoid lesions in exanthems of patients with COVID-19 infection.9,10 In addition, the presence of pseudo-vesicles and enanthem are two clues that suggest an infectious cause rather than a drug reaction. However, we cannot positively exclude the involvement of the various drugs administered to the patients. This is a first observation that will require further investigations.

Summary Background Cutaneous reactions after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines are poorly characterized. Objective To describe and classify cutaneous reactions after SARS-CoV-2 vaccination. Methods A nationwide Spanish cross-sectional study was conducted. We included patients with cutaneous reactions within 21 days of any dose of the approved vaccines at the time of the study. After a face-to-face visit with a dermatologist, information on cutaneous reactions was collected via an online professional survey and clinical photographs were sent by email. Investigators searched for consensus on clinical patterns and classification. Results From 16 February to 15 May 2021, we collected 405 reactions after vaccination with the BNT162b2 (Pfizer-BioNTech; 40·2%), mRNA-1273 (Moderna; 36·3%) and AZD1222 (AstraZeneca; 23·5%) vaccines. Mean patient age was 50·7 years and 80·2% were female. Cutaneous reactions were classified as injection site (‘COVID arm’, 32·1%), urticaria (14·6%), morbilliform (8·9%), papulovesicular (6·4%), pityriasis rosea-like (4·9%) and purpuric (4%) reactions. Varicella zoster and herpes simplex virus reactivations accounted for 13·8% of reactions. The COVID arm was almost exclusive to women (95·4%). The most reported reactions in each vaccine group were COVID arm (mRNA-1273, Moderna, 61·9%), varicella zoster virus reactivation (BNT162b2, Pfizer-BioNTech, 17·2%) and urticaria (AZD1222, AstraZeneca, 21·1%). Most reactions to the mRNA-1273 (Moderna) vaccine were described in women (90·5%). Eighty reactions (21%) were classified as severe/very severe and 81% required treatment. Conclusions Cutaneous reactions after SARS-CoV-2 vaccination are heterogeneous. Most are mild-to-moderate and self-limiting, although severe/very severe reactions are reported. Knowledge of these reactions during mass vaccination may help healthcare professionals and reassure patients.

We read with great interest the recently published letter on your journal "Development of eruptive pseudoangiomatosis following COVID-19 immunization- apropos of 5 cases",1 as we have just seen a case of this entity related to COVID-19 vaccine in our hospital.

A woman presented to the emergency department during the COVID-19 pandemic, reporting a slightly pruritic rash that had developed five days after the onset of fever, cough and malaise.

We thank the Biobank of University Hospital Ramon y Cajal.

Chilblain-like lesions (CLL) were described early on the coronavirus disease 2019 (COVID-19) pandemic as red-to-violet macules, plaques, or nodules typically appearing at the distal aspects of toes.1 Although increasing evidence suggests they are COVID-19-related,2 it is not supported by analytic controlled studies.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been recently linked to dermatologic manifestations and is thought to affect more severely patients with androgenetic alopecia. We designed a prospective multicentric study which enrolled patients from March to August of 2020 with acute telogen effluvium (ATE) that had a prior SARS-CoV-2 infection confirmed either by serological tests (e.g. detection of serum antibodies against the virus via enzyme-linked immunosorbent assays (ELISA)) or detection of viral RNA using real-time reverse transcription polymerase chain reaction (RT-PCR).

This case series describes the appearance of enanthem (oral cavity lesions) in patients with COVID-19.

Acute telogen effluvium has been recognised as a dermatological sequela of COVID-19.

Dermatological manifestations of the Coronavirus Disease 2019 (COVID‐19) may include unspecific macular erythematous rash, urticarial lesions and chickenpox‐like vesicles1,2. Acroischemic lesions have been described in two different types of COVID‐19 patients. Firstly, critically ill patients with severe limb ischemia and secondly, paucisymptomatic young patients with chilblain‐like lesions3. The etiopathogenesis and clinical implications of these lesions remains unclear.

COVID‐19 is a disease caused by severe acute respiratory syndrome coronavirus 2 of the genus Betacoronavirus (SARS‐CoV‐2). It was first described in Wuhan (China) on December 2019 and has spread to become a pandemic. Its clinical presentation is mainly characterized by cough, fever and dyspnea, although many other symptoms have been described within its presentation pattern. In some cases, it causes an acute respiratory distress that has lead to the death of thousands of people around the world. Furthermore, different types of skin lesions have been described during the infection period of illness.1 In this exceptional situation of global health emergency, physicians are undertaking research work in order to achieve notions on the etiopathogenesis of these skin lesions. The first report of cutaneous manifestations described different forms of skin lesions such as erythematous rash, urticaria and chicken‐pox‐like vesicles.2 Further studies have classified 5 different type of skin lesions, and associated them with patient demographics, timing in relation to symptoms of the disease, severity and prognosis.

We have read with great interest the article: Cutaneous manifestations in COVID‐19: a first perspective by Recalcati S.1 This article is the first report of the cutaneous manifestations in Coronavirus Disease 2019 (COVID‐19) patients during the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic in Lombardy, Italy.

The novel Coronavirus disease (COVID‐19) outbreak has been recently declared a pandemic by the World Health Organization (WHO), being Italy and Spain the worst‐hit European countries. Although the main clinical picture consists of fever and respiratory symptoms, an increasing number of studies have reported associated skin manifestations. Herein we present two patients with urticarial vasculitis arising in the context of COVID‐19 infection.

Background: In 2017, we carried out a cross-sectional study with the aim of describing androgenic alopecia (AGA) prescription habits among dermatologists who practice in Spain. Three years later, we repeated this study with the aim of describing the current situation and comparing it with previous data. Material and Methods: Descriptive cross-sectional study using online questionnaires autocompleted by dermatologists working in Spain. Results: The responses of 243 dermatologists were analyzed. The most common treatments prescribed for MAGA were topical minoxidil (100%), oral finasteride (92.6%), oral dutasteride (75.7%), and oral minoxidil (50.6%). For premenopausal female AGA (FAGA), the most common treatments were topical minoxidil (99%), oral contraceptives (75%), nutricosmetics (71%), and oral minoxidil (67.9%). Lastly, the most common treatments prescribed in patients with postmenopausal FAGA were topical minoxidil (99.2%), oral finasteride (79%), oral durasteride (71.6%), and oral minoxidil (63%). Conclusions: In conclusion, AGA is the most frequent alopecia in the trichology clinic. The most common treatments prescribed in male AGA (MAGA) and postmenopausal FAGA were topical minoxidil and oral finasteride, while in premenopausal FAGA, topical minoxidil, oral contraceptives, and nutricosmetics were most commonly prescribed. In the past three years, oral dutasteride and oral minoxidil have increased drastically among the most prescribed therapies for MAGA, premenopausal FAGA, and postmenopausal FAGA.

To the Editor:COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 of the genus Betacoronavirus (SARS-CoV-2). It was first described in Wuhan (China) on December 2019 and has spread to become a pandemic. Its clinical presentation is mainly characterized by cough, fever and dyspnea, although many other symptoms have been described within its presentation pattern. In some cases, it causes an acute respiratory distress that has lead to the death of thousands of people around the world. Furthermore, different type of skin lesions have been described during the infection period of illness due to SARS-CoV-2.1 The first report of cutaneous manifestations described different forms of skin lesions such as erythematous rash, urticaria and chicken-pox-like vesicles.2 In this exceptional situation of global health emergency, physicians are undertaking research work in order to achieve notions on the etiopathogenesis of these skin lesions. Acro-ischaemic lesions have also been notified and attributed to disseminated intravascular coagulation and to the expression of secondary microthrombosis due to endotelial damage.3-5However, to date, there is no clear understanding on whether the skin lesions are secondary to the viral infection nor why there are different presentations of skin lesions for the same viral infection.We present 4 patients with COVID-19, confirmed by positive polymerase chain reaction, who were referred to our service due to the appearance of skin lesions. Two of them developed skin lesions during hospitalization whilst presenting respiratory symptoms and the other two developed skin lesions many days after hospital discharge. Demographic data, description and histology of skin lesions, blood parameters, clinical symptoms and drugs administered are shown in table I. The algorithm of the spanish pharmacovigilance system (ASPS), which evaluates the possible implication of a drug reaction as a cause of the skin lesions6 was also applied. The ASPS analizes: i) the interval between drug administration and the aparition of skin lesions, ii) the degree of knowledge of the relationship between the drug and the effect described in literature, iii) the evaluation of drug withdrawal, iv) the rechallenge effect, and v) alternative causes. Each item receives and individual subscore, and a total sum ≥ 6 indicates a probable causality.6As mentioned above, skin lesions appear to be a sign within patients suffering from COVID-19. To date, no hypothesis has been proposed to explain if the lesions (including the different types) are attributable to the virus, to drug adverse reactions or to any other clinical condition. In our series, small enough to draw conclusions, we have found no differences between the multiple types of skin lesions and analytical or clinical features. Even in lesions with apparent vascular involvement, which have been associated with alterations in coagulation,3-5 the values detected do not differ from those with other types of skin lesions. Regarding drug involvement, since all the patients were exposed to multiple drugs at the same time, the ASPS was not able to differentiate the possibility of drug implication nor the immune mechanisms involved. Thus, further assays with selective (in vitro or in vivo ) tests for each drug seem necessary in order to completely rule out drug involvement. In addition, since many patients worldwide are being infected with SARS-Cov-2, and many of them present similar medical history and receive the same treatments, it seems necessary to investigate the existence of an individual predisposition that facilitates the developement of skin lesions. In this new scenario that we are facing in these last months, providing light on these still unresolved questions, can contribute to prevent or to manage the symptoms in an early way.

A severe cutaneous drug reaction resembling acute generalized exanthematous pustulosis resulting from ingestion of hydroxychloroquine has been documented. It is distinguishable by its longer incubation period, more varied morphology with initially urticarial and later targetoid and arcuate plaques, recalcitrance to therapy and longer duration. Given the anticipated surge in the use of hydroxychloroquine due to its reported benefits in those with coronavirus disease 2019, specific recognition of this entity is pivotal. We delineate it as generalized pustular figurate erythema.

COVID-19 is an infectious disease caused by severe acute respiratory coronavirus 2 (SARS-CoV-2). Vesicular skin rashes have been reported as associated with COVID-19, but there is little information about this cutaneous manifestation. We designed a prospective observational study of patients diagnosed with COVID-19 who had vesicular lesions. Clinical characterization of skin findings was conducted by dermatologists. When possible, histological analysis and detection of SARS-CoV-2 in the content of the vesicles was performed. In total, 24 patients were included. A disseminated pattern was found in 18 patients (75%), and a localized pattern was found in 6 (25%). Median duration of the skin rash was 10 days. Of the 24 patients, 19 (79.2%) developed the skin rash after the onset of COVID-19 symptoms. Histological examination in two patients was consistent with viral infection, SARS-CoV-2 was not detected in four patients. This single-centre study shows the clinical characteristics of vesicular skin rashes in patients with COVID-19.

Background The cutaneous manifestations of COVID-19 disease are poorly characterized. Objectives To describe the cutaneous manifestations of COVID-19 disease and to relate them to other clinical findings. Methods We carried out a nationwide case collection survey of images and clinical data. Using a consensus we described five clinical patterns. We later described the association of these patterns with patient demographics, the timing in relation to symptoms of the disease, the severity and the prognosis. Results The lesions may be classified as acral areas of erythema with vesicles or pustules (pseudo-chilblain) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%). Vesicular eruptions appear early in the course of the disease (15% before other symptoms). The pseudo-chilblain pattern frequently appears late in the evolution of the COVID-19 disease (59% after other symptoms), while the rest tend to appear with other symptoms of COVID-19. The severity of COVID-19 shows a gradient from less severe disease in acral lesions to more severe in the latter groups. The results are similar for confirmed and suspected cases, in terms of both clinical and epidemiological findings. Alternative diagnoses are discussed but seem unlikely for the most specific patterns (pseudo-chilblain and vesicular). Conclusions We provide a description of the cutaneous manifestations associated with COVID-19 infection. These may help clinicians approach patients with the disease and recognize cases presenting with few symptoms. What is already known about this topic? Previous descriptions of cutaneous manifestations of COVID-19 were case reports and mostly lacked illustrations. What does this study add? We describe a large, representative sample of patients with unexplained skin manifestations and a diagnosis of COVID-19, using a consensus method to define morphological patterns associated with COVID-19. We describe five clinical patterns associated with different patient demographics, timing and prognosis, and provide illustrations of these patterns to allow for easy recognition.

This cohort study assesses the association of inflammatory symptoms with the progression of hair loss in women with frontal fibrosing alopecia.