July 15, 2020 Enanthem in Patients With COVID-19 and Skin Rash Juan Jimenez-Cauhe, MD1; Daniel Ortega-Quijano, MD1; Dario de Perosanz-Lobo, MD1; Patricia Burgos-Blasco, MD1; Sergio Vañó-Galván, MD, PhD1; Montse Fernandez-Guarino, MD, PhD1; Diego Fernandez-Nieto, MD1 Article Information JAMA Dermatol. Published online July 15, 2020. doi:10.1001/jamadermatol.2020.2550 1 recently reported skin manifestations in 18 patients in Italy with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, or coronavirus disease 2019 (COVID-19), describing “erythematous rash,” “widespread urticaria,” and “chickenpox-like vesicles.” Additional reports have described other rashes, including petechial and purpuric changes,2 transient livedo reticularis,3 and acro-ischemic lesions.4 Whether these manifestations are directly related to COVID-19 remains unclear, since both viral infections and adverse drug reactions are frequent causes of exanthems. An important clue to distinguish between both entities is the presence of enanthem (oral cavity lesions).5 However, owing to safety concerns, many patients with suspected or confirmed COVID-19 do not have their oral cavity examined. Herein we describe variants of enanthem in a series of patients with COVID-19. 5 This study was approved by the institutional review board of Ramon y Cajal University Hospital in Madrid. Accordingly, informed consent was obtained verbally from all patients before examination, and they have been deidentified through omission of individual age and sex. 6 No enanthem was observed in patients with urticarial or typical maculopapular rashes. The enanthem was macular in 1 patient, petechial in 2 patients, and macular with petechiae in 3 patients, and was located in the palate in all patients (Figure). No patient presented with an erythemato-vesicular enanthem. The mean (range) time between the onset of COVID-19 symptoms and the appearance of mucocutaneous lesions was 12.3 days (range, −2 to 24 days). Interestingly, this latency was shorter in patients with petechial enanthem compared with those with a macular lesion with petechiae appearance. Drug intake and laboratory findings were not associated with any enanthem type (Table).
