COVID-19 produces a broad spectrum of cutaneous manifestations, ranging from transient inflammatory rashes in mild infection to severe vascular lesions in critically ill patients, according to a review published in The BMJ.
Clinicians have documented five principal categories of skin involvement: urticarial lesions, maculopapular eruptions, vesicular rashes, chilblain-like lesions (colloquially termed “covid toes”), and livedo or necrosis. The latter, alongside livedoid or retiform purpura and acral ischaemia, tends to occur in patients with severe disease and is associated with systemic coagulopathy and a poorer prognosis. Inflammatory and urticarial rashes, by contrast, are reported more frequently in mild or asymptomatic cases.
The predominant mechanism is indirect rather than direct viral invasion of skin cells. Endothelial dysfunction, platelet activation, and a dysregulated proinflammatory cytokine response appear to drive the vascular and cutaneous changes observed, particularly in severe disease. Chilblain-like lesions have specifically been linked to a robust interferon response. Clinicians should also note that some cutaneous findings, including hand and facial dermatitis, may reflect behavioural changes such as increased hand-washing or prolonged PPE use, rather than the infection itself.
In post-acute COVID-19 syndrome, dermatological manifestations differ from those in the acute phase. Alopecia is the most commonly reported finding, affecting up to 50% of patients with post-COVID skin effects, followed by pruritus, dermatitis, and pigmentation changes. Telogen effluvium has also been documented, predominantly in women, approximately two to three months after initial infection.
COVID-19 can additionally exacerbate pre-existing skin conditions, including psoriasis, atopic dermatitis, and chronic urticaria, through immune activation, mast cell triggering, and treatment disruptions. Clinicians are advised to monitor patients on immunomodulatory therapies and counsel them on flare management accordingly.
Source: Lang K., The BMJ (2026). DOI: 10.1136/bmj.s264
