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Covid Rash

What Is It, Signs, Symptoms, Treatment, and More

Author:Anna Hernández, MD

Editors:Alyssa Haag,Emily Miao, PharmD,Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:Stacy M. Johnson, LMSW


What is a COVID rash?

COVID rash is a general term to describe the cutaneous manifestations associated with COVID-19 infection. COVID-19, or coronavirus disease discovered in 2019, is a respiratory infection caused by SARS CoV-2, which stands for severe acute respiratory syndrome coronavirus 2. Although COVID-19 is best known for causing respiratory symptoms, it has also been associated with several extrapulmonary manifestations, including cardiac dysfunction, renal failure, gastrointestinal symptoms, and skin manifestations.

Cutaneous manifestations of COVID-19 are grouped into five major categories, including morbilliform rashes (i.e., a skin rash containing rose-red flat or slightly elevated lesions, resembling measles); urticaria (i.e., itchy, red welts); vesicles (i.e., small blisters); pseudo-chilblains, also known as “COVID toes” (i.e., painful inflammation of the toes in response to cold); and vaso-occlusive skin lesions due to thrombosis and occlusion of small arteries.

Toes with morbilliform rash.

What causes the COVID rash?

The exact cause of skin involvement in COVID-19 is not clear. However, research suggests it may be associated with how SARS-COV-2 enters the cells. SARS-COV-2 is a virus that enters the body through the angiotensin-converting enzyme 2 (ACE2) receptor, which is found in epithelial cells of various body tissues, including the skin. The primary role of the ACE2 receptor is to modulate the function of angiotensin II, a protein essential for regulating blood pressure. ACE2 converts angiotensin II to other molecules that counteract angiotensin’s harmful effects, such as increased cell inflammation. When SARS-CoV-2 binds to ACE2 receptors on the surface of cells, the receptor’s action is inhibited, thereby making more angiotensin II available to tissues.  It is thought that the accumulation of angiotensin II contributes to lung damage, blood vessel dysfunction, and increased vascular permeability, which may lead to skin rashes. Another possible theory is that COVID-19 particles in cutaneous blood vessels may disturb the immune system response and trigger the release of pro-inflammatory molecules, resulting in blood vessel inflammation, microvascular injury, thrombotic events, and occlusion of small arteries. 

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What are the signs and symptoms of a COVID rash?

The most common skin manifestations of COVID-19 are morbilliform rashes, which consist of an itchy, generalized, maculopapular rash with flat or slightly elevated lesions that are rose-red. Urticaria, also known as hives, is also common in COVID-19. Clinical features typically consist of raised, well-defined wheals that are usually red, blanch with pressure, are incredibly itchy, and can present anywhere in the body. Next, vesicular eruptions may also occur in the setting of COVID-19, either localized or distributed throughout the body. Both urticaria and vesicles appear before the onset of the other general COVID-19 symptoms. 

Chilblains, or "COVID toes," on the other hand, were the first noted cutaneous manifestations associated with COVID-19. However, their link with COVID infections has since been debated. Chilblains consist of small, itchy swellings on the skin that occur as a reaction to cold temperatures and most commonly affect the body's extremities, such as the toes, fingers, heels, ears, and nose. Finally, vaso-occlusive lesions have been reported in individuals with COVID-19 with several different presentations, including livedo reticularis, purpuric lesions, and acral ischemia. These lesions are most frequently seen in hospitalized individuals with moderate to severe COVID-19 and are associated with more severe disease than the other skin manifestations. 

How is a COVID rash diagnosed?

Diagnosis of COVID skin rashes relies on a detailed medical history and physical exam. In some cases, COVID-19 skin manifestations may be attributed to comorbid conditions, adverse skin reactions, drug-induced (i.e., from the various COVID treatments) seasonal viral infections, or occupational skin diseases. However, keeping a high index of suspicion of COVID-19 infection can help guide early testing, especially if skin manifestations precede other symptoms. In cases where the diagnosis is uncertain, a skin biopsy of the lesions can be helpful to confirm the diagnosis or rule out other skin conditions. 

How is a COVID rash treated?

Treatment of skin manifestations associated with COVID-19 is primarily based on the symptoms and may involve topical corticosteroids and oral antihistamine medications. Some manifestations, such as most skin rashes, COVID toes, and urticarial lesions, tend to resolve spontaneously in a short period. Therefore, observation and supportive measures may be recommended. 

What are the most important facts to know about the COVID rash?

COVID-19 is a respiratory infection caused by the SARS-CoV-2 virus. Most people with COVID-19 experience fever, fatigue, and respiratory symptoms. However, a small percentage may develop a rash and other skin manifestations associated with COVID-19 (i.e., COVID toes, urticaria, vesicular eruptions, and vaso-occlusive skin lesions). Diagnosis of COVID-19 skin manifestations requires a high index of suspicion and relies on a detailed history and physical exam. Treatment is mainly symptomatic, involving topical corticosteroids and antihistamines, though most COVID-19 rashes may be managed with a “watch and wait” strategy as they typically resolve spontaneously. 

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Related links

COVID-19 (Coronavirus Disease 19)
COVID-19 vaccines: What healthcare providers need to know
Post-COVID syndrome: Heart, lungs, and clotting

Resources for research and reference

Genovese G, Moltrasio C, Berti E, Marzano A. Skin manifestations associated with COVID-19: current knowledge and future perspectives. Dermatology. 2020;237(1):1-12. doi:https://doi.org/10.1159/000512932

‌Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID-19. Nature Medicine. 2020;26(7):1017-1032. doi:https://doi.org/10.1038/s41591-020-0968-3

Polly S, Fernandez AP. Common skin signs of COVID-19 in adults: an update. Cleveland Clinic Journal of Medicine. 2022;89(3):161-167. doi:https://doi.org/10.3949/ccjm.89a.21126

Sodeifian F, Mushtaq S, Rezaei N. Cutaneous manifestation of COVID-19: what have we learned a year into the pandemic? Actas Dermo-Sifiliográficas. 2022;113(2):157-165. doi:https://doi.org/10.1016/j.ad.2022.01.023

Tan SW, Tam YC, Oh CC. Skin manifestations of COVID-19: a worldwide review. JAAD international. 2021;2:119-133. doi:https://doi.org/10.1016/j.jdin.2020.12.003