Spanish Study Identifies 5 Skin Manifestations in COVID-19 Patients

The cutaneous manifestations in patients with different severities of COVID-19, as well as cutaneous lesions in those with mild symptoms or asymptomatic disease, sparked the interest of a group of Spanish researchers led by Dr. Alba Català and Dr. Cristina Galván. The investigators decided to conduct a study that would characterize these lesions and relate them to other clinical findings.

The study, conducted from 3 to 16 April 2020, described 5 major clinical patterns. This classification of the cutaneous manifestations of COVID-19 has helped to improve the understanding of disease severity and the temporal relationship (the different times and durations that lesions appear) during the course of the infection. It is the first study to classify COVID-19-associated skin lesions and provide an atlas of images of them.

In a videoconference interview (one of the many activities incorporated in our new way of living with the COVID-19 virus that allows us to stay close despite our distances), Dr. Català discussed her research.

Dr Català, a Spanish dermatologist, is an associate professor at Hospital Plató in Barcelona. She is one of the main authors of the COVID-19 study. A Spanish version of the study, entitled “COVID-19 y piel/COVID-19 and the Skin,” was published in the Spanish journal Actas Dermo-Sifiliográficas.¹ An English version, entitled “Classification of cutaneous manifestations of COVID-19: A rapid prospective nationwide consensus study in Spain with 375 cases,” was published in the British Journal of Dermatology.²

Dr Català said the idea for this study was initiated by chance. She and Dr. Galván, a dermatologist at the Hospital Universitario de Móstoles, Madrid, met when each of them joined an online dermatology chat group to gather as much information as possible about this novel virus. At the time in March 2020, information about COVID-19 and skin symptoms was scarce.

One of the doctors participating in the chat presented the case of a COVID-19 patient with a skin rash and no other symptoms to see if other participants had patients with similar clinical findings. Drs. Català and Galván exchanged ideas and decided to collect information about cases that were flooding social networks. Eager to contribute to the understanding of COVID-19, especially its skin manifestations, they decided to conduct a national study. Their goal was to characterize the skin manifestations associated with the disease and investigate their possible diagnostic, prognostic, and epidemiological value.

The study protocol was designed in conjunction with Dr. Gregorio Carretero, a Spanish dermatologist at the Hospital Universitario de Gran Canaria. It began after approvals by an ethics committee and the Spanish Drug Agency.

With the help of the Spanish Academy of Dermatology and Venereology (AEDV), the researchers requested the collaboration of all Spanish dermatologists. Taking into account the high workload imposed on these doctors, many of whom were reassigned to the acute care of patients with COVID-19, they designed a simple online questionnaire.

Initially, their objective was to collect at least 60 cases in a span of 2 weeks during the peak of the pandemic. Due to the extensive participation of their colleagues, they obtained 120 cases by the middle of the recruitment period. By the end of the 2 weeks, they had collected 430 cases, 375 of which were entered into the study.

Drs. Català and Galván were also assisted by the research unit of AEDV’s Piel Sana Foundation, which was responsible for technical support, guidance, and statistical analysis, and for ensuring good research practices. The AEDV publicized the study through social networks and the media reported on it as well. The publicity prompted patients to ask their doctors to be included in the study.

More than 100 dermatologists from hospitals, private centers, and outpatient clinics across Spain participated in the study. Dr. Català credited the “solidarity” of these colleagues as well as that of COVID-19 patients who were willing to participate in the study for its completion and national distribution. All of the participants, she said, were eager to help understand more about this new disease.

For her part, Dr. Català said the study has reinforced her own research skills and helped her learn more about COVID-19. The study’s worldwide distribution has given her the satisfaction of having contributed to the knowledge about this challenging disease.

Another lesson from this national, collaborative study: Its completion in such a short time and during a time of so much adversity shows that joint effort and teamwork are key to achieving extraordinary results.