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Table of Contents
Year : 2022  |  Volume : 26  |  Issue : 3  |  Page : 21-22

Generalized exanthem as a presenting symptom of COVID-19

1 Department of Dermatology and Dermatologic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Division of Dermatology and Dermatologic Surgery, Security Force Hospital, Riyadh, Saudi Arabia

Date of Submission05-Dec-2020
Date of Decision31-May-2021
Date of Acceptance30-Jun-2021
Date of Web Publication22-Aug-2022

Correspondence Address:
Dr. Lama N Altawil
Department of Dermatology, Prince Sultan Military Medical City, P O Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_138_20

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Coronavirus disease 2019 (COVID-19) has many cutaneous manifestations. We describe a 30-year-old otherwise healthy male with a generalized purpuric exanthem. Ten days after the onset of the rash, he presented with fatigue, dry cough, shortness of breath, anosmia, and ageusia and was diagnosed as having COVID-19. The presence of an extensive exanthem in an otherwise healthy patient could raise suspicion for underlying COVID-19.

Keywords: Coronavirus disease 2019, cutaneous, erythroderma, papulosquamous, purpura, pustules, severe acute respiratory syndrome coronavirus 2

How to cite this article:
Altawil LN, Alajroush NA. Generalized exanthem as a presenting symptom of COVID-19. J Dermatol Dermatol Surg 2022;26, Suppl S1:21-2

How to cite this URL:
Altawil LN, Alajroush NA. Generalized exanthem as a presenting symptom of COVID-19. J Dermatol Dermatol Surg [serial online] 2022 [cited 2022 Dec 8];26, Suppl S1:21-2. Available from: https://www.jddsjournal.org/text.asp?2022/26/3/21/354304

  Introduction Top

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as a novel coronavirus infecting humans in China in early December 2019.[1] As of March 2020, coronavirus disease 2019 (COVID-19) was officially announced to be a global pandemic by the World Health Organization.[2] The viral infection can present with fever, cough, headache, myalgia, asthenia, and anosmia.[1],[3] Cutaneous manifestations of COVID-19 are manifold. We describe a patient who developed a generalized exanthem before the development of any other systemic symptoms of COVID-19.

  Case Report Top

In June 2020, a 30-year-old otherwise healthy Saudi male presented to our emergency department complaining of a 6-day history of an asymptomatic skin rash. Affected areas initially involved the trunk and progressively spread to include both upper and lower extremities. He was working as a dog breeder and denied any contact with ill patients, recent travel, or consumption of prescribed or over-the-counter medications, supplements, herbs, or illicit substances.

On exam, he was a well-appearing man with Fitzpatrick IV skin type. He was conscious, oriented, and vitally stable, with a temperature of 36.7°C, blood pressure of 121/76 mmHg, pulse rate 98 bpm, respiratory rate 19 per min, and oxygen saturation of 100% on room air. Skin examination revealed almost 85% body surface area affected by red nonblanchable papules and plaques admixed with follicular hyperkeratotic plugs, pustules, and blanchable macules over the trunk [Figure 1]a,[Figure 1]b,[Figure 1]c. On his lower limbs, he had scattered dusky red palpable and nonpalpable purpura. The primary lesions coalesced into larger plaques measuring over 4 cm in diameter over the medial proximal thighs and knees bilaterally [Figure 1]d. The face, flexural sites, fingers, toes, palms, and soles were spared. Nail and mucus membranes were unremarkable. Moreover, no target or targetoid lesions and no evidence of bullae were observed, and Nikolsky's sign was negative. There was no evidence of hepatomegaly, splenomegaly, or lymphadenopathy. The differential diagnosis included small vessel vasculitis, pityriasis rubra pilaris, pustular psoriasis, and drug eruption.
Figure 1: Generalized red nonblanchable papules and plaques admixed with follicular hyperkeratotic plugs and pustules and blanchable macules over the (a) Anterior trunk. (b) Posterior trunk and right arm. (c) Numerous papules surrounded by erythema over the right forearm. (d) Numerous scattered dusky red palpable and nonpalpable purpura coalescing into larger plaques over the proximal medial thighs and knees bilaterally

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Complete blood count, coagulation profile, complete metabolic profile, hepatitis viral screen, urinalysis, C-reactive protein, and erythrocyte sedimentation rate were within the normal range. A chest X-ray was normal. Two 3 mm punch biopsies, one for hematoxylin and eosin with bacterial and fungal stains and one for direct immunofluorescence (DIF), were obtained. The patient was discharged home on 80 mg prednisolone for 1 week, prophylactic fluconazole 150 mg at days 0 and 3, clobetasol admixed with fusidic acid cream daily for 1 week and when necessary, levocetirizine 5 mg at bedtime, and loratadine 10 mg in the morning if itching developed until his return visit after 1 week.

Three days later, the patient returned for follow-up with fatigue, a dry cough, shortness of breath, anosmia, and ageusia. The patient recalled gathering with COVID-19-positive friends 1 week before the onset of his skin eruption. On examination, the patient was vitally stable, and his skin eruption markedly improved. SARS-CoV-2 nasopharyngeal reverse transcriptase-polymerase chain reaction was performed and was positive. Skin biopsy results were nonspecific, showing subcorneal neutrophils, acanthosis, mild spongiosis, and extravasated red blood cells with a superficial perivascular lymphocytic infiltrate without evidence of skin necrosis. DIF, bacterial, and fungal stains returned as negative. Prednisolone was tapered at 20 mg decrements weekly until 20 mg was reached for his second follow-up appointment. The patient did not need any hospital admission, and his respiratory symptoms resolved 5 days from onset. Consent for publication by provided by the patient.

  Discussion Top

Cutaneous involvement was reported in 18 of 88 COVID-19 patients in Italy. Skin findings described included erythematous rash (n = 14), widespread urticaria (n = 3), and chicken pox vesicles (n = 1).[4] In a recent international registry of 716 patients from 31 countries, the most common cutaneous findings were summarized in descending order as morbilliform, pernio-like, urticarial, macular erythema, vesicular, papulosquamous, and retiform purpura.[5] Recognizing the different patterns may aid in predicting the severity of the disease. Those with pernio-like lesions tend to have a milder form, and those with retiform purpura, true acral ischemia, and fixed livedo racemosa may be critically ill. The onset of skin manifestations is variable, of which 12% develop before the onset of respiratory symptoms.[5] In a recent literature review, lesions developing before fever and respiratory symptoms were in the form of urticarial, periorbital dyschromia, or painful blisters localized to a certain body area.[6] Herein, we present a patient with an asymptomatic generalized exanthem with both purpuric and perifollicular hyperkeratotic plugs with nonspecific biopsy findings presenting 10 days before the onset of respiratory symptoms. Prompt recognition of COVID-19 in this global pandemic is necessary. We believe that the presence of such extensive lesions in an otherwise healthy patient should raise suspicion for underlying COVID-19.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
Timeline of WHO's Response to COVID-19. Available from: https://www.who.int/news-room/detail/29-06-2020-covidtimeline. [Last accessed on 2020 Jun 30].  Back to cited text no. 2
Lechien JR, Chiesa-Estomba CM, De Siati DR, Horoi M, Le Bon SD, Rodriguez A, et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): A multicenter European study. Eur Arch Otorhinolaryngol 2020;277:2251-61.  Back to cited text no. 3
Recalcati S. Cutaneous manifestations in COVID-19: A first perspective. J Eur Acad Dermatol Venereol 2020;34:e212-3.  Back to cited text no. 4
Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Desai SR, et al. The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries. J Am Acad Dermatol 2020;83:1118-29.  Back to cited text no. 5
Kaya G, Kaya A, Saurat JH. Clinical and histopathological features and potential pathological mechanisms of skin lesions in COVID-19: Review of the literature. Dermatopathology (Basel) 2020;7:3-16.  Back to cited text no. 6


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