LAUSR

Cutaneous manifestation of COVID-19 reporting from Middle-Eastern countries: A point of view! Dear Editor, Cutaneous signs/rashes in association with the COVID-19 pandemic have a conflicting incidence that has varied from 0.2% in a cohort of Chinese patients to 20.4% in an Italian cross-sectional study. These cutaneous signs are polymorphic, including erythema, chilblain-like, and urticarial lesions, to name a few, and may be underestimated or under-recognized by nondermatologists owing to lack of the typical respiratory signs of the disease in some patients that might lead to misdiagnosis or delayed diagnosis of patients with atypical/extrapulmonary presentations. It is unclear whether these signs are host-specific, are contributing pathogenic factors leading to its development, or it is merely a coincidental phenomenon. The clinical and the prognostic significance of these signs remains uncertain or unexplored, until further studies. Dermatologists interested in investigating SARS-CoV-2, who are recruited to bolster pandemic-fighting staffs, can play an important role in diagnosing and managing paucisymptomatic COVID-19 cases. As "evils don’t always come to hurt", there is an unprecedented plethora of academic productivity in reporting cutaneous signs of COVID-19 or entailing COVID-19 from a dermatologic perspective. However, rigorous peer-review was not the norm for most of the reports. Kittler et al. noted that there was no revision in 54.4% of the published articles. It was unclear whether some of these publications were born to some kind of predatory journals. Notably, reports from Middle-Eastern countries are scarce and limited mainly to case reports despite a higher preponderance rate of infection. Herpes zoster, cutaneous small vessel vasculitis, chilblain-like lesions, wart-like lesions, oral vesicles, and pityriasis rosea were among the reported signs. It is unclear whether cutaneous signs reported from these nations were truly few or similarities of the reports and poor documentation played a role in its lower priority for publication. Lack of sufficient knowledge and familiarity with the reported cutaneous signs of the disease is another reason. With a higher predominance of female dermatologists, those with children may be participating in academic work less and have lower submission rates compared to their male counterpart.Moreover, nondermatologists may generically describe skin lesions of the patients under their care as a skin "rash" that may not warrant dermatology consultation, particularly if asymptomatic or when afflicting a critical case. There is a general "misconception" about dermatologists being rather cosmetologists than competent physicians serving a nonacute specialty that may result in underestimating the dermatologists’ wakeup call reports at a situation where how to manage a patient with respiratory failure is more important. Subsequently, experts have stressed the important role of dermatologists as "dermatology hospitalists" to assist in the rebirth of the liaison between dermatology and general internal medicine and to marry them up in practice. Intercommunication between dermatologists and colleagues from other specialties is also helpful in mitigating work-related burnout. Up to the time of writing this manuscript, there is no official or authorized protocol for COVID-19 screening based solely on the "presumed" cutaneous signs, despite being a forefront of the disease or harboring a possible serious pathology. Being a red zone of political, economical, and somewhat religious conflicts, the main interest of these countries is to control the situation with limited sequels. Eventually, not all asymptomatic individuals are subjected to testing if not from “high-priority” areas. Involving cutaneous signs into the list of workup indications to rule out COVID-19 may add more burden on these countries that have disparities in their social, structural and, more importantly, healthcare systems, swapping the existing acute services for the middle income ones. Given the scarcity of papers from Middle-Eastern countries and global racial disparities in infection and mortality rate, dermatologists should be encouraged to report whatever possible cases of skin manifestations in confirmed COVID-19 patients to help in creating a registry related to their ethnic population. This reporting could contribute to early diagnosis and potentially better health outcomes. While awaiting these data, it is crucial to all dermatologists to be knowledgeable of the wide variety of skin manifestations in patients with COVID-19 in their clinical practice. Reporting new data should be through well-known, peer-reviewed journals.