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Year : 2022  |  Volume : 67  |  Issue : 2  |  Page : 192-194
Atypical erythema multiforme revealing COVID-19

From the Department of Dermatology, Fattouma Bourguiba University Hospital, University of Monastir, Tunisia

Date of Web Publication13-Jul-2022

Correspondence Address:
Mouna Korbi
From the Department of Dermatology, Fattouma Bourguiba University Hospital, University of Monastir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_617_21

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How to cite this article:
Said R, Korbi M, Belhadjali H, Zili J. Atypical erythema multiforme revealing COVID-19. Indian J Dermatol 2022;67:192-4

How to cite this URL:
Said R, Korbi M, Belhadjali H, Zili J. Atypical erythema multiforme revealing COVID-19. Indian J Dermatol [serial online] 2022 [cited 2022 Aug 17];67:192-4. Available from:


The flare-up of COVID- 19 has been declared as a public health emergency of international concern by the World Health Organization and a threat for the health professionals across the planet.

The highly infectious phase of COVID-19 and asymptomatic carriage have played a role in its rapid transmission and spread all over the world, leading to the most disastrous public health crisis in over a century.[1]

A variety of dermatological manifestations caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been described.

We report a case with an atypical presentation of erythema multiforme as the initial manifestation of COVID-19.

A 52-year-old female patient, with no particular medical history, presented with an itchy rash evolving for 10 days. She denied any drug intake before the onset of cutaneous lesions. The dermatological examination found fixed papular erythematous lesions with a pseudo-cocarde form, which first appeared on the face [Figure 1] and then on the dorsal parts of the hands and the extension sides of the elbows and knees [Figure 2] without mucosal involvement. We noted scratches linearly distributed on the thighs [Figure 3]. Moreover, there was no mucocutaneous herpes infection preceding the eruption. The patient was apyretic with a good general condition.
Figure 1: Fixed papular erythematous lesions with a pseudo-cocarde form on the face

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Figure 2: Pseudo-cocarde lesions on the dorsal part of the hand (a) and the knee (b)

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Figure 3: Scratches linearly distributed on the thighs

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Based on this clinical aspect, we evoked an atypical erythema multiforme. Laboratory examinations were within normal levels, especially showing a negative Mycoplasma polymerase chain reaction (PCR) and an old immunization for human herpes virus (HSV) through antibody test.

The query revealed a prior COVID-19 contact, and a PCR SARS-CoV-2 was requested, which came back positive. Few days later, the patient developed COVID's respiratory symptomatology. She was treated symptomatically on an outpatient basis, which resulted in clinical improvement of the eruption within 2 weeks.

The most frequent cutaneous manifestation described during coronavirus infection has been maculopapular exanthema, but there is also papulovesicular rash, urticaria, pseudo-chilblain, and livedo reticularis or necrosis.[2]

These skin lesions were explained by the microvasculopathy associated with the infection.[2]

Other dermatoses, due to the stress in the context of COVID-19 infection, have been reported, such as seborrheic dermatitis, alopecia, and telogen effluvium.[3]

The erythema multiforme caused by COVID-19 is characterized by its atypical appearance and clinical polymorphism.[4] Few cases have been described, with a female predominance of these lesions, which were especially observed during the asymptomatic phase, like in our patient.[4]

The mean time period between the onset of COVID-19 symptoms and the cutaneous lesions was 19.5 days.[4]

The diversity of skin lesions, which may happen before, during, or after the beginning of other COVID-19 symptoms, is remarkable compared to other viral infections.

The physiopathological mechanism of skin manifestations in COVID-19 has not been elucidated yet. It is uncertain whether cutaneous symptoms are a secondary consequence of respiratory-related infection or a primary infection of the skin itself.[5]

Even in the absence of a COVID-19 diagnosis, dermatological manifestations should be carefully evaluated during this pandemic period.

In asymptomatic or presymptomatic patients, these skin findings may be a valuable signal of infection, contributing to timely diagnosis and appropriate management of the disease.

Physicians should be aware that atypical erythema multiforme can represent another pattern associated with COVID-19.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents 2020;55:105955.  Back to cited text no. 1
Singh H, Kaur H, Singh K, Sen CK. Cutaneous manifestations of COVID-19: A systematic review. Adv Wound Care (New Rochelle) 2021;10:51-80.  Back to cited text no. 2
Turkmen D, Altunisik N, Sener S, Colak C. Evaluation of the effects of COVID-19 pandemic on hair diseases through a web-based questionnaire. Dermatol Ther 2020;33:e13923.  Back to cited text no. 3
Gül Ü. COVID-19 and dermatology. Turk J Med Sci 2020;50:1751-9.  Back to cited text no. 4
Sachdeva M, Gianotti R, Shah M, Bradanini L, Tosi D, Veraldi S, et al. Cutaneous manifestations of COVID-19: Report of three cases and a review of literature. J Dermatol Sci 2020;98:75-81.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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