Window to COVID-related clues

What skin manifestations tell us about COVID-19.

Esther Ellen Freeman, MD, PhD, FAAD
Esther Ellen Freeman, MD, PhD, FAAD

S021 – COVID-19 Dermatology and Vaccines
Saturday, March 26 | 9 a.m. – 12 p.m.
Room: Ballroom West

Why do people respond differently to the COVID-19 virus — and the vaccine? Do dermatologists have a window into clues?

Skin manifestations of the virus and the vaccine can tell us a lot, according to Esther Ellen Freeman, MD, PhD, FAAD, principal investigator for the COVID-19 Dermatology Registry, a collaboration with the AAD and International League of Dermatological Societies, and an associate professor of dermatology at Harvard Medical School. Dr. Freeman will lead this morning’s session session, S021 – COVID-19 Dermatology and Vaccines, which looks at everything from COVID skin manifestations to the dermatologist’s influence in educating patients about the vaccine.

“There is a wide spectrum of COVID-19 skin manifestations. Over 30 different skin manifestations have been identified to date, and these often serve as clues to how our immune system is responding to COVID,” she said.

According to Dr. Freeman, mild COVID symptoms often accompany milder skin manifestations, such as pernio chilblains, sometimes referred to as “COVID toes.” Patients with moderate symptoms of COVID might present with hives or a vesicular eruption. Severe COVID symptoms, in which a patient is hospitalized and on a ventilator, may be accompanied by retiform purpura, signifying more serious coagulation issues.

Similar virus, different people

“The virus presents very differently in different people,” Dr. Freeman said. “It’s the same virus. The difference is in how a patient’s immune system responds to it.” Dermatologic clues are often related to COVID variants as well, Dr. Freeman said. As such, she encourages dermatologists to use these clues, particularly since many see their patients regularly and are a trusted resource.

“When you see a new or unexplained rash, consider COVID-19 if you don’t have another answer. The threshold to do a COVID test in your office should be low. In the beginning, it was hard to access those tests, but now we can, Dr. Freeman said. We know that in COVID cases where patients experience a rash, up to 20% of them may have a rash as either the first, or the only symptom. For example, new-onset hives without other explanation can be the first symptom of COVID-19.”

It’s important to meet your patient where they are and understand why they may be experiencing vaccine hesitancy,” she said.

Vaccination progression

For patients who already had a vaccine reaction to an earlier dose, dermatologists can provide counseling on the expected course with future vaccinations. Dr. Freeman said most patients are able to complete their vaccine series.

“We’ve had patients with hives, patients with blisters, patients with morbilliform rashes, who have all gone on to tolerate further vaccine doses,” Dr. Freeman said. “Worldwide, over 10 billion vaccines have been given. Vaccines are incredibly safe and effective, and there’s no guarantee that just because you had a reaction with the first vaccine dose that you will have the same or worse with the second or the booster. In fact, a reaction occurs after the second dose less than 50% of the time. And the reaction usually disappears on its own after two weeks.” 

Because vaccine reactions can last longer in some cases, Dr. Freeman emphasizes dermatologists play an important role in reducing the transmission and severity of COVID-19 through vaccination. The AAD/ILDS COVID-19 Dermatology Registry is still accepting cases at

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