Chilblains and pruritus: the dermatologist will show how Covid-19 eats into the skin
The skin itches, it blisters form on toes swelling: Some skin changes can indicate infection with the novel Coronavirus. Spanish dermatologists have described and explain how they are related to the Severity of a Covid-19-disease.
The disease Covid-19 has many faces. Only after the people know you. Currently it shows: the skin reacts in some patients, the infection with the novel Coronavirus.
Therefore, the dermatolog studied interior Cristina Galván Casas from the Hospital Universitario de Móstoles in Madrid and Alba Català from the Hospital Plató in Barcelona, with colleagues, unexplained skin changes. Of the 375 patients from the whole of Spain had a probable or confirmed Sars-CoV-2 infection behind (BJD 2020; online 29. April).
The analysis of photos and medical Findings led the skin doctors five clinical Patterns of skin diseases, some of which were described in case reports from physicians in other countries.
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1. Pseudo-Frostbite
Swelling, sometimes with pustules and vesicles, were reddish to purple on the hands and feet of 19 percent of the patients (Acral erythematous swelling). As the skin changes are visually similar to frostbite, call a physician them as the “Pseudo-chilblains” (“Pseudo-Chilblain”). Similar symptoms were reported by dermatologists from other countries also. American dermatologists speak out already, the so-called “Covid-toe” in the list of Covid-19 symptoms include. Italian Doctors called the phenomenon in a case report of an “epidemic” of skin lesions of the feet of children and young adults.
Because the Pseudo-chilblains seem to tend to young patients to relate to, the little symptoms and the mild course have. A third of the respondents in the Spanish study found the changes to the skin as a painful or itchy. Also entered the skin reactions are relatively late in the disease course to.
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In Germany, Uwe Kirschner from the professional Association of German dermatologists, and his colleagues have previously observed no increase of unusual skin lesions that the virus spread close. The slopes but certainly so that many patients are currently practices rather reluctant to visit a doctor, in order to protect yourself from a possible coronavirus infection.
A connection of the Pseudo-chilblains with a Covid-19-disease of the dermatologist was definitely possible. “The presumed Pathomechanisms would fit, and it may well be that such a relatively rare phenomenon occurs in the case of a new pathogen, more frequently,” explains Kirschner. However, it is at the moment still speculative, how frequently such skin changes in Covid-19 patients occur.
Treat painful frost could be bumps in any case, usually with steroid-containing creams and ointments. But even without treatment they heal after twelve to 20 days. 
Academia Española de Dermatología Sars-CoV-2 could Pseudy-frostbite trigger.
2. Bubbles-Like Outbreaks
More bubble-like eruptions (vesicular eruptions) showed nine percent of the Surveyed in Spain. Affected by the often itchy skin changes were patients of middle age. In addition, they performed especially in the early stages of the Covid-19-disease on – at 15 percent of the patients already before the other symptoms. The small blisters, blood filled, similar to chicken pox, enlarged, or spread. They found predominantly on the trunk, but also on the limbs. Overall, was this Symptom with moderately severe disease associated.
All of the following skin changes observed in the Spanish dermatologists in parallel to other Covid-19-symptoms such as cough or fever. 
Academia Española de Dermatología researchers suggest that the Coronavirus is from the bubble-like eruptions cause can.
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3. Hives
So-called urticarial lesions were found in 19 percent of patients. Mostly had to be Concerned with the hull, in some cases, on the inside of the Hand, in order to fight mainly with itching. 
Academia Española de Dermatología , The scientists noticed besides urticarial lesions.
These skin lesions showed some similarities to the next pattern, the observed, the Spanish dermatologist:
4. Flaking and redness
The makulopapulären eruptions characterize varying degrees of flaking of the skin. Point-shaped or large areas of redness were also observed.
Common to all of the symptoms below 3 and 4 that the itchy Spots less in length, showed, than, for example, the Pseudo-chilblains. Also hung with a severe course of the Covid-19-disease together.
At the same time, the study authors consider that this corona patients had received more drugs than those with a mild history. Therefore, the skin reactions were not differentiated clearly from the side effects of it. 
Academia Española de Dermatología Also itchy flaking and redness observed by the researchers in connection with Covid-19.
5. Necrosis
A very severe (mortality rate in this group: ten percent) of the associate dermatologists of the necrosis (also Livedo) to. Six percent of the patients suffered from different severe skin damage through lack of blood supply to the hull, but also the fingers and toes, and around the nose, chin and ear. These skin changes were mostly older Covid-19-patients.
Whether the described skin changes are actually triggered by Sars-CoV-2 or a Co-infection going back, we need further investigations. Nevertheless the dermatologist to Galván Casas just see the Pseudo-chilblains, as well as the bubble-like eruptions as a helpful note on a Covid-19-disease. 
Academia Española de Dermatología researchers suggest that the Coronavirus can lead to necrosis (Livedo) can lead to.
When should be Concerned, go to the doctor?
“Whenever such changes to the skin serious side effects, such as fever, General physical weakness, etc, occur,” says Kirschner. So, for example, meningococcal Sepsis can cause similar symptoms. Then an idea in the hospital should be, because these are serious emergencies.
Skin lesions due to Kawasaki syndrome
On the skin is also the Kawasaki-syndrome can have an impact. From the U.S., “the New York Times reported” about children who suffered along with other symptoms underneath a skin rash. According to the report, has been demonstrated in the case of the most Affected with the Coronavirus or at least Corona antibodies. Even Doctors from the UK warn in the least in severe cases in children in connection with Covid-19 and an Overreaction of the body’s own immune system (autoimmune reaction).
The Kawasaki syndrome is a very rare inflammation of the small and medium-sized blood vessels. Since these supply all of the organs in the body, can, in principle, develop all the organs. Skin, mucous membranes, and lymph nodes, however, are particularly at risk.
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What are the changes to the skin typically?
“The most common and also very impressive Symptom are always swollen, deep red lips, as well as the strawberries, or coating of the tongue,” explains Uwe Kirschner. This swelling of the Lymph nodes, inflammation of the conjunctiva come skin in mind, skin rashes, which can be very varied and certainly to anyone with measles or scarlet fever can remember, as well as a Purpura Schoenlein-Hennoch (which are the size of a pinhead multiple hemorrhages, typically in drooping parts of the body). Other symptoms are swelling of the hands and feet, with typical Flaking, if this reducing the swelling as well as swelling of the neck lymph nodes.
Also to the Hyper inflammation syndrome skin symptoms include
In the meantime, children, doctors distinguish, however, the typical Kawasaki syndrome inflammatory syndrome in connection with Covid-19. There is a statement by the German society for paediatric infectiology (DGPI) and the German society for paediatric cardiology and Congenital heart defects (DGPK).
The doctors make it clear that such Hyper-inflammation syndromes, excessive inflammatory reactions, are on the whole rare, and “in the case of children however, even before the Covid-19-pandemic well-known”. Different diseases, especially of infections with viruses and bacteria may trigger such severe inflammatory responses (Cytokine storms). For Covid-19 symptoms, signs of vascular inflammation have been described on the fingers and toes. “In General, this excess is meant to treat inflammation very well with cortisone or other immunosuppressive agents, and immunoglobulins,” write the experts.
Kirschner points out that patients with Kawasaki or Hyperinflammationssysdrom would be taken care of in the rule already stationary. Fever and the inflammatory processes were in the foreground of the treatment. The skin doctor adds: “in addition, it must be clarified that the coronary vessels, lungs and other internal organs are not affected, or not affected. Due to the above-mentioned treatment, disappearance of the skin symptoms.“
Excessive inflammatory reaction is rare
The physician of the opinion are demanding that pediatricians give the symptoms described an increased attention. The United States and the United Kingdom had already issued a nationwide warning, reported Alexander Kekulé in his MDR-Podcast. “The Robert Koch Institute should point out that this rare disease should be observed – especially when we open the schools again,” says the virologist. It is important to inform pediatricians that are so far a little with such a disease into contact. However, he did not think that there are going to be in Germany a lot of cases.
Finally, the pediatricians at ease with Hyper inflammation syndrome: “The absolute numbers of cases are very low and should, therefore, lead to any General concern of the parents.”
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