University of Wisconsin–Madison Medical College of Wisconsin

Early Cutaneous Manifestations of COVID-19: A Systematic Review and Public Health Implications

Abhinav Grover, MBBS, MD, MS; Franchesca Choi, RPh, MD; Sheng-Pei Wang, MD

WMJ. 2023;122(5):349-356

Download full-text pdf


Introduction: Cutaneous manifestations before other symptoms have great potential for early COVID-19 diagnosis to prevent surge.

Methods: We conducted a search of PubMed and Embase databases through April 11, 2021 to include 39 studies reporting skin manifestations occurring prior to any other COVID-19 symptoms in laboratory-confirmed cases.

Results: Ninety-seven patients were included. Urticarial (24.7%) and maculopapular (22.7%) lesions were most common, followed by pernio (17.5%), vesicular (14.4%), papulosquamous (8.2%), and purpuric (5.1%) lesions. Cutaneous to systemic symptom latency ranged from 2 to 20 days in cases that reported it (26%), while skin lesions were the only presentation in 23 cases (23.7%). Skin lesions were the only COVID-19 manifestation in 58.8% of pernio, 40% of vesicular, 16.6% of urticarial, 18.2% of maculopapular, and 12.5% of papulosquamous presymptomatic cases. Although sample size is limited, all purpuric cases developed other symptom(s) later.

Conclusions: Pernio and purpuric lesions have been well-associated with COVID-19, but papulosquamous, vesicular, mild maculopapular, and urticarial lesions can easily be dismissed as unrelated to COVID-19. Pernio lesions are thought to be related to strong immune response and low contagiousness, while purpuric and vesicular cases are speculated to be related to higher SARS-CoV2 viral load, severity, and contagiousness. All rashes, even without other symptoms, should necessitate high level of suspicion for isolation or contact tracing.

Author Affiliations: Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (Grover); Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (Choi); DermAI, Taipei, Taiwan (Choi, Wang); National Cheng Kung University International Research Center of Wound Repair and Regeneration, Tainan, Taiwan (Wang); University of Southern California Department of Pathology, Los Angeles, California (Wang).
Corresponding Author: Abhinav Grover, MBBS, MD, MS, Medical College of Wisconsin Department of Pathology and Laboratory Medicine, Milwaukee, WI; email; ORCID ID 0000-0001-8580-3141
Funding/Support: None declared.
Financial Disclosures: None declared.
Share WMJ