COVID-19: Cutaneous manifestations and issues related to dermatologic care

INTRODUCTION — 

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), raises many issues in dermatology and dermatologic care.

This topic will discuss issues related to dermatologic care during the COVID-19 pandemic. Other relevant aspects of SARS-CoV-2 infection and patient management are discussed in detail separately.

●(See "COVID-19: Epidemiology, virology, and prevention".)

●(See "COVID-19: Clinical features".)

●(See "COVID-19: Diagnosis".)

●(See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

●(See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting".)

●(See "COVID-19: Hypercoagulability".)

●(See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)

●(See "COVID-19: Management in hospitalized adults".)

●(See "COVID-19: Considerations in patients with cancer".)

●(See "COVID-19: Care of adult patients with systemic rheumatic disease".)

CUTANEOUS MANIFESTATIONS OF COVID-19

Frequency — Studies from around the world have identified a range of potential dermatologic manifestations of COVID-19 [1-8]. Reports of the prevalence of cutaneous manifestations in patients with COVID-19 vary, ranging from less than 1 percent to more than 20 percent of patients [9-17]. Data from two large population-based studies suggest frequencies of cutaneous manifestations (before the Delta variant) in the range of 10 to 13 percent [13,14].

Clinical presentations — The COVID-19 Dermatology Registry, a collaboration between the American Academy of Dermatology and the International League of Dermatological Societies, was generated in 2020 to collate cases and better define the cutaneous manifestations of COVID-19 [18]. (See 'Registries' below.)

In a 2020 analysis of 171 patients with laboratory-confirmed COVID-19 and cutaneous manifestations from the registry, the most commonly reported cutaneous manifestations were morbilliform rash (22 percent), pernio-like acral lesions (18 percent), urticaria (16 percent), macular erythema (13 percent), vesicular eruption (11 percent), papulosquamous eruption (9.9 percent), and retiform purpura (6.4 percent) [19]. Fever and cough were reported in approximately 60 percent of cases.

●Exanthematous (morbilliform, maculopapular) rash – In several case series, a morbilliform rash predominantly involving the trunk has been reported as the most common cutaneous manifestation of COVID-19 [2,3,10,19-21]. The rash has been noted either at the disease onset or, more frequently, after hospital discharge or recovery [10].

●Pernio (chilblain)-like acral lesions – Pernio (chilblain)-like lesions of acral surfaces ("COVID toes") present as erythematous-violaceous or purpuric macules on fingers, elbows, toes, and the lateral aspect of the feet, with or without accompanying edema and pruritus (picture 1 and picture 2). (See "Pernio (chilblains)".)

•Incidence – Pernio-like lesions have been increasingly reported across the age spectrum during the COVID-19 pandemic, with most cases occurring among adolescents and young adults. In a northern California study, the incidence of chilblains increased during the pandemic (April 2020 to December 2020) compared with the prepandemic period (April 2016 to December 2019), from 5.2 per 100,000 person-years (95% CI 4.8-5.6) to 28.6 per 100,000 person-years (95% CI 26.8-30.4) [22].

•Association with SARS-CoV-2 infection – During the pandemic, pernio-like lesions have been reported in patients with or without confirmed COVID-19 or a history of contact with patients with confirmed COVID-19 and in the absence of documented cold exposure or underlying conditions associated with pernio [2-4,19,22-30]. Among individuals with pernio-like lesions, SARS-CoV-2 polymerase chain reaction (PCR) positivity rates ranged from 3 to 7 percent during the wild-type wave of the pandemic but decreased during the subsequent waves of SARS-CoV-2 variants. Positive serology rates of 1 to 17 percent (mainly for SARS-CoV-2 immunoglobulin G [IgG] and immunoglobulin M [IgM]) have been reported in a limited number of patients with pernio-like lesions and negative PCR for SARS-CoV-2 [4,22,31,32].

•Clinical presentation and course – The majority of patients with pernio-like lesions and confirmed or suspected SARS-CoV-2 infection were asymptomatic or had mild symptoms compatible with COVID-19, with very rare reports of severe COVID-19 in patients with pernio-like lesions [2,4,33-35]. In the American Academy of Dermatology/International League of Dermatological Societies registry study, 55 percent of patients overall were otherwise asymptomatic, and 98 percent of patients in the study were treated in the outpatient setting alone [4]. This finding held true when restricted to laboratory-confirmed cases only, with 78 percent remaining in the outpatient setting.

In patients with confirmed or suspected SARS-CoV-2 infection, pernio lesions started one to four weeks after the onset of COVID-19 symptoms, suggesting a postviral or delayed-onset process. In the American Academy of Dermatology/International League of Dermatological Societies registry, 80 of 318 cases with pernio-like lesions developed lesions after the onset of other COVID-19 symptoms [4]. In some cases, lesions appeared while patients were still PCR positive for the virus [4,30].

Resolution usually occurred in two to eight weeks. A prolonged course of more than 60 days has been reported in some patients ("long haulers") [36]. Additionally, some patients have developed recurrence of pernio, likely triggered by cold, during the following fall-winter season [37,38].

•Potential pathogenetic mechanisms – Biopsied pernio-like lesions demonstrate a primarily inflammatory process, with histopathologic and direct immunofluorescence findings similar to those seen in idiopathic and autoimmune-related pernio [3,26,28,39-42]. (See "Pernio (chilblains)", section on 'Skin biopsy'.)

Proposed mechanisms for the development of pernio-like lesions during the pandemic include:

-A reaction to the immune response to the virus, possibly associated with enhanced interferon-alpha responses to the virus or with an immunoglobulin A (IgA) antibody response to the virus [33,36,43,44].

-Pandemic-related lifestyle changes that may increase the risk for pernio. In a large cohort study that included 780 patients with pernio seen during the pandemic, 94 percent reported not wearing shoes at home [22].

•Management – The management of COVID-19-associated, pernio-like lesions of the feet or hands is similar to that of idiopathic pernio. (See "Pernio (chilblains)", section on 'Management'.)

●Livedo reticularis-like vascular lesions – Livedo reticularis-like vascular lesions have been reported in a few patients with COVID-19 [19,24,45-49]. In a series of 171 laboratory-confirmed cases, these vascular lesions were noted in 5.3 and 2.3 percent of patients, respectively [19].

●Fixed livedo racemosa/retiform purpura/necrotic vascular lesions – Retiform purpura and necrotic vascular lesions seem to be associated with severe COVID-19 (picture 3 and picture 4) [19,24,50,51]. In a series of 11 patients with retiform purpura and laboratory-confirmed COVID-19, all were hospitalized and nine had acute respiratory distress syndrome (ARDS) [19]. In three patients with SARS-CoV-2 infection and severe respiratory failure who had retiform purpura or livedo racemosa, histologic and immunohistochemistry studies of skin biopsies revealed a pattern of complement-mediated microvascular injury in both involved and normally appearing skin [50]. Histopathologic findings of thrombotic vasculopathy and/or laboratory coagulation alterations have also been demonstrated in patients with severe COVID-19 and acral ischemic lesions [39,51]. (See "Approach to the patient with retiform (angulated) purpura" and "Livedoid vasculopathy" and "COVID-19: Hypercoagulability".)

●Urticaria – Acute urticaria with or without concomitant fever has been reported as a presenting sign of COVID-19 infection [2,3,10,19,24,52].

●Vesicular (varicella-like) eruptions – There are several reports describing a vesicular-pustular, varicella-like eruption associated with COVID-19 [2,24,53,54]. In a series of 24 patients, an eruption of small papules, vesicles, and pustules appeared 4 to 30 days after the onset of COVID-19 symptoms and resolved in a median of 10 days [55]. A real-time PCR for SARS-CoV-2 from vesicle content performed in four patients yielded negative results. Seventeen of 24 patients were not taking any medications, ruling out a drug reaction.

●Multisystem inflammatory syndrome in children (MIS-C) – An erythematous polymorphic rash, erythema and/or firm induration of hands and feet, oral mucositis, and conjunctivitis, along with systemic, laboratory, and imaging findings of atypical severe Kawasaki disease, were initially described in a cohort of 10 Italian children during the COVID-19 pandemic [56]. Similar cases have been reported in the United Kingdom [57], the United States [58], and other countries. The case definition for MIS-C is discussed in detail elsewhere. (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis", section on 'Case definition'.)

Less frequently reported dermatologic manifestations include papulosquamous eruptions [59], erythema multiforme-like lesions [60-62], dengue-like rashes [63,64], petechiae [65], and gangrene [66].

Some infants born to mothers with COVID-19 at birth have had transient rash. In a review of nine small case series from China that included a total of 65 pregnant women who were infected with SARS-CoV-2 during pregnancy and 67 newborns, two newborns presented with a rash [67]. The rash has been described in one infant as a diffuse, maculopapular eruption that resolved in one day with desquamation and in another as a diffuse, red, miliaria-like eruption that disappeared in 10 days without treatment [68].

DERMATOLOGIC CONDITIONS RELATED TO THE COVID-19 PANDEMIC — 

Skin injury, mechanical/friction dermatitis, and irritant contact dermatitis due to personal protective equipment (PPE) and hand hygiene measures have been reported in the majority of health care workers involved in the direct care of patients with COVID-19 [69].

Personal protective equipment-induced skin injury — Health care workers caring for patients with COVID-19 or patients potentially infected with SARS-CoV-2 may spend long hours wearing PPE. The American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic.

●Mechanical injury/friction dermatitis – PPE-induced skin injury can occur in health care workers [69-72]. Long durations of PPE use (>6 hours per day) increase rates of skin damage [69,70,73]. Masks, goggles, face shields, and gloves apply pressure, create abrasion, retain moisture, and can injure the nasal bridge, cheek, forehead, and hands [69-71]. PPE-induced injuries include desquamation, erythema, maceration, fissuring, papules, and erosions, leading to itching and pain [70].

●Irritant and allergic contact dermatitis – Multiple case series have reported allergic contact dermatitis due to rubber, adhesives, and formaldehyde and irritant contact dermatitis due to pressure and friction in health care workers wearing N95 or equivalent masks for >6 hours daily [74,75].

●Facial dermatoses ("maskne") – New-onset or exacerbation of facial dermatoses, including acne ("maskne"), rosacea ("mask rosacea"), seborrheic dermatitis, periorificial dermatitis, and folliculitis, likely due to friction and occlusion, have been reported in persons wearing masks for >6 hours per day [74,76,77]. Mask-related Koebner phenomenon (trauma-induced development of lesions clinically similar to the underlying skin disease in previously uninvolved areas) has also been described in patients with a variety of skin disorders, including psoriasis, vitiligo, acne, and rosacea [78].

Prevention of PPE-related injuries has the potential to reduce PPE protocol breaches due to inadvertent adjustment and touching [79]. The use of barrier films or dressings at pressure points before donning PPE may reduce these types of injuries [80-84]. However, the effects of these preventive measures on PPE ability to prevent viral spread are not well characterized, and caution is warranted [79,82].

Hand hygiene-related dermatitis — Hand hygiene is considered a key tool against COVID-19. Hand eczema was already an issue among health care workers and is likely to be an even greater problem with higher rates of hand washing and glove use during the pandemic [85].

The frequency of irritant contact dermatitis of the hands may be reduced by frequent usage of emollients, washing with lukewarm water instead of hot water, and usage of alcohol-based cleansers when hands are not visibly dirty [80,83,86,87]. Overzealous hand hygiene may cause hand eczema in the general population as well [88].

The American Academy of Dermatology has released recommendations on preventing and treating occupationally induced dermatologic conditions during the COVID-19 pandemic. (See "Irritant contact dermatitis in adults" and "Chronic hand eczema".)

THERAPEUTIC CONSIDERATIONS

Use of immunosuppressive drugs in patients with COVID-19 — Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases, such as psoriasis, atopic dermatitis, and other inflammatory or autoimmune conditions. The decision to continue or discontinue treatment in a patient with COVID-19 should be made on a case-by-case basis. Factors that may influence the decision to cease treatment may include the patient's COVID-19 vaccination status, the severity of COVID-19, and the potential negative ramifications of treatment cessation on flaring immunologic activity, including both dermatologic disease and comorbidities. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Management of patients with SARS-CoV-2 infection'.)

Advanced skin cancer — Issues related to the care of patients with cancer are discussed elsewhere. (See "COVID-19: Considerations in patients with cancer".)

COVID-19 VACCINATION — 

Vaccines to prevent SARS-CoV-2 infection are reviewed in detail separately. (See "COVID-19: Vaccines".)

Cutaneous adverse events — Examples of reported cutaneous reactions following receipt of COVID-19 vaccines have included injection site reactions, delayed large local reactions (also known as "COVID arm"), urticaria, morbilliform eruptions ("maculopapular rash"), pityriasis rosea-like reactions, pernio/chilblains, bullous pemphigoid-like reactions, lichen planus-like reactions, purpuric reactions, herpes zoster, and other findings [89-96].

Cutaneous and other adverse events following COVID-19 vaccines should be reported. (See 'Registries' below.)

Frequency — A systematic review and meta-analysis of studies from 2019 to 2022 that assessed cutaneous adverse events following COVID-19 vaccination provided data on the frequency of cutaneous adverse events [97]. The pooled prevalence of cutaneous manifestations was 3.8 percent (95% CI 2.7-5.3 percent, I² = 99.77) among recipients of messenger ribonucleic acid (mRNA)-based vaccines, inactivated SARS-CoV-2 vaccines, or viral vector-based vaccines. Acute local injection site reactions were the most frequent cutaneous manifestations, accounting for 72 percent of the 44,582 reported cases of vaccine-related cutaneous manifestations. Subgroup analysis also suggested a higher prevalence of cutaneous adverse events in association with mRNA vaccines compared with other vaccine platforms (prevalence of 6.9 percent, 95% CI 3.8-12.3 percent). Limitations of the meta-analysis included high heterogeneity, uncertain causality between vaccination and reported cutaneous outcomes, and incomplete descriptions of cutaneous outcomes in some reports.

Much higher frequencies of injection site reactions reported in some trials reflect the inclusion of "pain" within the category of injection site reactions (ie, cutaneous manifestations not required) [98].

Clinical presentations — Features of some of the most reported cutaneous adverse effects include:

●Injection site reactions – Acute injection site reactions are common after vaccination against COVID-19 and other diseases [96,98,99]. Typical symptoms include the development of swelling, erythema, and pain at the vaccination site within one to two days after vaccination. Symptoms usually resolve within several days. Symptomatic treatment can be implemented when needed. These reactions are not considered contraindications to future vaccination. (See "Allergic reactions to vaccines", section on 'Delayed vaccine reactions'.)

●Delayed local reactions – A delayed local reaction secondary to COVID-19 vaccination (also known as "COVID arm") is an immune-mediated reaction characterized by the development of a well-demarcated, inflamed plaque near the site of mRNA vaccination (picture 5). In contrast to typical injection site reactions, which appear within one to two days after vaccination, the usual time of onset is seven to eight days after initial vaccination, although delayed local reactions can occur more rapidly after repeat vaccinations [90]. (See "Allergic reactions to vaccines", section on 'Delayed vaccine reactions'.)

Delayed local reactions have been most frequently reported following initial vaccination and appear to be more commonly reported in females compared with males [91,100,101]. Clinically, delayed local reactions may be mistaken for cellulitis, but infection after vaccination is uncommon.

Generally, reactions spontaneously resolve within several days, though longer durations have been reported [100]. These reactions typically resolve without treatment, other than symptomatic treatment for pain or pruritus. They are not a reason to discourage future vaccination or boosters.

Patients with delayed local reactions can receive subsequent COVID-19 vaccines [90]. Although it appears most patients do not have recurrences with subsequent COVID-19 mRNA vaccination, earlier-onset delayed local reactions (eg, reactions appearing within one to five days) have occurred after a second vaccine dose in some patients who had a delayed local reaction after an initial vaccine dose [90,91,100].

The mechanism of these reactions is unclear; skin biopsies have demonstrated findings consistent with delayed-type hypersensitivity reactions [90,100,102].

●Delayed-onset urticaria – Delayed-onset urticaria after vaccination (eg, urticaria developing more than four hours after vaccination, not part of an immediate reaction) has been reported with original vaccine series and after booster doses [91,103-108]. In addition, a subset of patients may develop chronic spontaneous urticaria lasting ≥6 weeks [95,108-110].

The incidence of urticaria following vaccination may vary among vaccines. In a study that assessed data from allergist patients identified to have chronic spontaneous urticaria after COVID-19 vaccination in Switzerland (primarily recipients of Moderna or Pfizer-BioNTech boosters), chronic spontaneous urticaria was more frequently reported among recipients of a Moderna booster [95]. Urticaria typically first appeared one to two weeks after vaccination.

The approach to treatment of urticaria associated with COVID-19 vaccination resembles the approach to urticaria due to other causes. Antihistamines are the mainstay of treatment. Patients with refractory chronic spontaneous urticaria that cannot be controlled with antihistamines alone may benefit from other treatments. Improvement with omalizumab after failure of antihistamines is described in a case report [109]. (See "New-onset urticaria (hives)", section on 'Management' and "Chronic spontaneous urticaria: Standard management and patient education", section on 'Stepwise approach to treatment'.)

Although we do not consider chronic spontaneous urticaria a contraindication to COVID-19 revaccination, we take an individualized approach to subsequent vaccine boosters, considering the risks and benefits of vaccination for individual patients.

●Morbilliform eruptions – Morbilliform eruptions have been reported after COVID-19 vaccination [96]. The typical clinical findings are widespread, erythematous macules. Associated erythema may be subtle in patients with darkly pigmented skin.

Morbilliform eruptions usually spontaneously resolve within one to two weeks [91]. Management consists of supportive therapy for associated symptoms (eg, topical corticosteroids, antihistamines). Morbilliform eruptions are not considered contraindications for future vaccination.

●Vaccine-related eruption of papules and plaques – The term "vaccine-related eruption of papules and plaques" (V-REPP) has been proposed for the group of cutaneous COVID-19 vaccination reactions characterized by the histologic finding of spongiotic dermatitis and the clinical findings of papulovesicular (severe V-REPP), pityriasis rosea-like (moderate V-REPP), and papulosquamous skin lesions (mild V-REPP) [94].

V-REPP reactions generally appear at least several days after vaccination and may persist for weeks, months, or longer. In one registry-based study that included 15 patients with findings consistent with V-REPP following receipt of an mRNA vaccine, the median time to development of the eruption was 12 days after vaccination, and many patients continued to have active eruptions at the time of reporting [94]. Several patients who developed pityriasis rosea-like lesions after a first dose of an mRNA vaccine experienced a flare after a second dose of the vaccine.

Development of V-REPP is not considered a contraindication to future vaccine doses. However, given the possibility of persistent eruptions, shared decision making is important.

●Herpes zoster – A 2022 systematic review of the literature identified 160 reports of patients who developed herpes zoster after COVID-19 vaccination [96]. Although vaccine-related immunomodulation was proposed as a potential mechanism, additional study is necessary to confirm a causative relationship.

●Reactions to soft tissue fillers – Reports of facial swelling following receipt of the mRNA 1273 (Moderna) COVID-19 vaccine in patients with a history of facial soft tissue filler injections suggest a relationship between prior cosmetic soft tissue filler injections and postvaccination swelling, although such reports are rare, and additional data are necessary to confirm an association. A 2022 systematic review identified 16 cases of facial swelling after COVID-19 vaccination in patients with a history of soft tissue fillers and three additional cases following COVID-19 infection [111].

Given the apparent rarity of this adverse event and the expectation for complete resolution of associated facial swelling, decisions to proceed with soft tissue filler injections in close proximity to receipt of the vaccine may involve consideration of patient and provider tolerance for risk for facial swelling as well as consideration of the risks of delaying COVID-19 vaccination. (See "Injectable soft tissue fillers: Overview of clinical use".)

Severity grading — A proposed grading schema for generalized cutaneous adverse events to COVID-19 vaccines was adapted from the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) drug reaction scale [112]. (See "Common terminology criteria for adverse events".)

A proposed grading schema for localized reactions to COVID-19 vaccines based on the severity of pain, erythema or redness, induration and swelling, and tenderness was adapted from the US Food and Drug Administration (FDA) Toxicity Grading Scale [112].

Vaccination of immunocompromised patients — Vaccine efficacy may vary based on the type of immunomodulatory therapy and vaccine [113]. Guidance regarding the administration of COVID-19 vaccines in immunocompromised patients is provided separately. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals' and "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'COVID-19 vaccination while on immunosuppressive therapy'.)

REGISTRIES

COVID-19 — Registries on COVID-19 and the skin have been developed with the goal of increasing knowledge of the dermatologic manifestations and impact of COVID-19 in patients with dermatologic disease.

An example is the American Academy of Dermatology/International League of Dermatological Societies COVID-19 Registry for general dermatologic manifestations of COVID-19 or patients with COVID-19 and any pre-existing dermatologic condition.

Multiple disease-specific registries were also developed during the initial outbreaks, including on psoriasis (PsoPROTECT and SECURE-Psoriasis Registry), hidradenitis suppurativa (Global Hidradenitis Suppurativa COVID-19 Registry), and pernio (COVID Acral Ischemia/Perniosis in Children Registry).

Disease registries for rheumatologic diseases are reviewed separately. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Disease registries'.)

COVID-19 vaccine reactions — Reactions to COVID-19 vaccines should be reported. Resources for reporting adverse events include:

●All adverse events:

•Vaccine Adverse Event Reporting System (The United States Centers for Disease Control and Prevention)

●Cutaneous adverse events:

•COVID-19 Dermatology Registry (American Academy of Dermatology and International League of Dermatological Societies)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics" and "Society guideline links: COVID-19 – Dermatology care".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)" and "Patient education: COVID-19 and children (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Cutaneous manifestations of COVID-19 – Multiple skin manifestations have been described in patients with confirmed or suspected SARS-CoV-2 infection. These include a morbilliform rash, urticaria, pernio-like acral lesions, livedo-like vascular lesions, and vesicular varicella-like eruptions. A severe multisystem inflammatory syndrome with mucocutaneous, systemic, laboratory, and imaging findings of atypical severe Kawasaki disease has also been reported in children and adolescents with COVID-19. (See 'Cutaneous manifestations of COVID-19' above and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis" and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome".)

●Personal protective equipment and hand hygiene-related dermatoses – Skin injury, mechanical/friction dermatitis, and hand irritant contact dermatitis due to personal protective equipment (PPE) and hand hygiene measures have been reported in health care workers involved in the care of patients with COVID-19. Use of barrier films or dressings at pressure points of PPE and frequent use of emollients after hand washing may help reduce skin damage and irritation. (See 'Dermatologic conditions related to the COVID-19 pandemic' above.)

●Use of immunosuppressive therapies for skin disease in patients with COVID-19 – Active infection is an accepted indication for discontinuation of immunosuppressive therapies. However, the decision to continue, discontinue, or resume immunosuppressive treatment in patients with presumed or confirmed COVID-19 should be made on a case-by-case basis. (See 'Use of immunosuppressive drugs in patients with COVID-19' above.)

●Cutaneous adverse effects of COVID-19 vaccines – Multiple cutaneous adverse events have been described in association with COVID-19 vaccines. Examples include injection site reactions, delayed local reactions, urticaria, morbilliform eruptions, and vaccine-related eruption of papules and plaques (V-REPP). Most of these reactions are not contraindications to future COVID-19 vaccines or boosters. (See 'Cutaneous adverse events' above.)