The number of COVID-19 cases, particularly those involving pregnancy, continues to be an issue in India and around the world. Fever (temperature>38°C), cough, and shortness of breath are the primary clinical signs. It can also be accompanied by weariness, myalgia, gastrointestinal issues like diarrhoea, and even freshly discovered skin condition signs [1-2].

Due to the physiological and mechanical changes associated with pregnancy, pregnant women are a high-risk demographic. Though it protects the foetus, T-helper2 (Th2) system dominance in particular makes pregnant women more prone to infections. However, there hasn't yet been enough research done in the literature on COVID-19 cutaneous symptoms in pregnant and lactating patients [1-2].

The researchers identified a number of factors that should make pregnant women extra careful during the COVID-19 pandemic. Pregnant women are insensitive to hypoxia due to physiological changes in their immunological and cardiac systems during pregnancy [1-2].

Understanding the cutaneous signs of SARS-CoV-2 infection can aid in early diagnosis and better maternal-fetal outcomes. SARS-CoV-2 infection during pregnancy can cause severe, life-threatening illness [1,3].

Skin symptoms in pregnant COVID-19 individuals are still an uncommon occurrence. Skin symptoms may be an early indicator of such an infection, thus doctors must be aware of them in order to conduct early COVID-19 screening in expectant mothers for the benefit of the mother and the unborn child [1,4].

Pregnant women should be aware of the primary dermatological SARS-CoV-2-related patterns that have been characterized. Despite the possibility of polymorphic skin lesions in SARS-CoV-2 patients, the research has identified six typical patterns: 

• Maculopapular

• Urticarial

• Vesicular

• Chilblain-like

• Livedo and Purpuric-Vasculitic patterns. 

Lesions that are inflammatory and exanthematous make up the first three groups, and cutaneous vasculitic diseases and vasculopathies make up the last three groups. These trends have been seen in various pregnancy-related skin conditions, highlighting the value of a thorough differential dermatologic diagnosis [1,5].

Several skin manifestations, including maculopapular eruptions, erythematous, varicelliform, and morbilliform rashes, urticaria, chickenpox-like lesions, livedo reticularis, the infamous "COVID toes," erythema multiforme, and pityriasis rosea, have been linked to COVID-19, according to a case report published in the journal Cutis [1-2].

There have been accounts of pregnant SARS-CoV-2 infected women who only experienced maculopapular eruptions and preterm membrane rupture. Maternal infections with maculopapular lesions have occasionally been documented to transmit SARS CoV-2 to the foetus. SARS-CoV-2 antiviral medication can cause pharmacological reactions that resemble viral eruptions, making it difficult to identify the initiating agent. Pregnant women may develop maculopapular lesions from Polymorphic Eruption of Pregnancy (PEP), also known as PUPP (Pruritic Urticarial Papules and Plaques of Pregnancy), and Atopic Eruption of Pregnancy (AEP). In order to properly intervene to avoid problems and transmission, SARS CoV-2 infections must be taken into consideration in the differential diagnosis of maculopapular eruptions in pregnant women [1,6].

PEP is the main skin condition to distinguish from a medicine or infection when it comes to pregnancy. PEP typically develops in primigradas late in the third trimester or in the postpartum phase and starts in the abdominal striae. Unlike PEP, the urticaria associated with SARS-CoV-2 usually goes away within 7 days [1,3].

Recent studies have demonstrated that SARS-CoV-2 infection or SARS-CoV-2 vaccination can cause chronic urticaria, which is more common in young women. Due to the potential for mild to severe illness consequences, SARS-CoV-2 should be taken into account in the differential diagnosis of urticaria in pregnant women without constitutional symptoms [1,4].

In the differential diagnosis of vesicular eruptions in pregnant women, SARS-CoV-2 infection must be taken into account. Viral and bacterial infections, infestations, miliaria, irritating or contact dermatitis, and autoimmune illnesses are among the causes that need to be removed. Viruses such the herpes simplex virus (HSV), varicella zoster virus (VZV), measles, and rubella must be distinguished since they are linked to severe foetal sequelae. Reactivation of HSV and VZV has been linked to SARS-CoV-2 infection, with some patients experiencing more severe sickness. When atopic dermatitis flares, it can cause vesicular lesions in children and pregnant women as well as secondary staphylococcal or HSV infections that need rapid medical attention. The atopic dermatitis flare-up may be caused by elevated IL-4 levels during pregnancy [1,3,5].

The differential diagnosis of SARS-CoV-2 vesicular exanthems should take Pemphigoid Gestationis, a rare immunobullous disease of pregnancy that often manifests in the third trimester and causes periumbilical bullae, into consideration [1-2].

According to recent studies, there may be an increased risk of herpes zoster (HZ) infection in pregnant women. Because of this, specialists advise that the clinical presentation of HZ in expectant women be closely observed and documented for further investigation, particularly if it is linked to other COVID-19 symptoms [2-3].

Of all the skin lesions connected to SARS-CoV-2, chilblain-like or "pernio-like" vascular skin lesions of the hands and feet are arguably the most well-known. The term "Covid toes" was first used to describe a variety of non-blanching erythematous or violaceous toe lesions related to SARS-CoV-2 infection. Late in the disease's progression, chilblain-like lesions may be the solitary symptom of SARS CoV-2 in pregnant women. It is crucial to correctly identify this pattern and rule out any primary or secondary causes [1,3].

Livedo patterns have been linked to SLE and antiphospholipid antibody syndrome, two other hypercoagulable disorders, in pregnant women. It's interesting to note that patients with severe thrombosis, livedo lesions, and SARS-CoV-2 infection also have antiphospholipid antibodies. Given the increased risk for serious SARS-CoV-2 consequences, pregnant women who present with livedo patterns and are infected should be constantly watched and checked for potential thrombotic events [1,4].

Other viral infections in pregnant women, such as hepatitis, the human immunodeficiency virus, parvovirus B19, as well as bacterial infections, hematologic, autoimmune, and nutritional problems, may also cause purpuric, petechial, or vasculitic lesions. Due to the wide range of therapies used in severe sickness, adverse medication reactions, especially those caused by antiviral drugs, are frequently the cause of purpuric vasculitic eruptions in SARS Co-V-2. The differential diagnosis of purpuric vasculitic lesions in pregnancy includes systemic lupus erythematosus, thrombotic thrombocytopenic purpura, anti-neutrophil cytoplasmic antibody related vasculitis, and parvo B-19 infections, all of which can have substantial perinatal and foetal consequences [1-2,5].

In conclusion, it would be wise to look into how hormonal and immunological changes unique to pregnancy can alter Covid19 cutaneous symptoms, especially during this crucial pandemic phase. Although there are few publications on the connection between SARS-Co-V-2 infection and associated dermatologic symptoms in expectant women, reports have shown this patient category is very susceptible to SARS-Co-V-2 sequelae. The severity of the condition can be predicted by skin lesions, which may be the first symptom of infection. Purpuric and vasculitic lesions, as well as fewer instances of chilblains-like lesions, have been linked to severe morbidity and mortality. Asymptomatic infections can be correctly recognized, disease transmission can be stopped, and life-threatening illness consequences can be avoided by recognizing skin symptoms in pregnant women who have SARS-Co-V-2. In order to allow for early intervention, therapeutic care, and the prevention of short- and long-term sequelae, it is essential to recognize skin symptoms in pregnant women who have contracted SARS-CoV-2. Differentiating from other skin conditions that can flare up during pregnancy due to physiologic immunological changes is also crucial.

1. Young E.M. "Perinatal/maternal-fetal-infant dermatologic manifestations of SARS-CoV-2: an overview and implications for diagnosis, treatment, and prognosis." Front Pediatr, vol. 10, 2022, article 1071839.

2. Sulistyowati S. et al. "Skin manifestations of COVID-19 in a pregnant woman with premature rupture of membranes: a case report." JKKI J Kedokteran Kesehatan Indones, vol. 12, no. 1, 2021, pp. 98–104.

3. Pharmacy Times. "Herpes zoster may be a sign of COVID-19 in pregnancy." Available at: https://www.pharmacy times.com/view/herpes-zoster-may-be-a-sign-of-covid-19-in-pregnancy (accessed on January 19, 2023).

4. Proietti I. et al. "Polymorphic eruption of pregnancy as a possible COVID-19 manifestation." Available at: https://www.sbmfc.org.br/wp-content/uploads/2020/0 8/10.1111@dth.14117.pdf (accessed on January 19, 2023).

5. MDedge. "Herpes zoster may be a marker of COVID-19 infection during pregnancy." Available at: https://www. mdedge.com/dermatology/article/233024/infectious-di seases/herpes-zoster-may-be-marker-covid-19-infection-during (accessed on January 20, 2023).

6. UpToDate. "COVID-19: cutaneous manifestations and issues related to dermatologic care." Available at: https://www.uptodate.com/contents/covid-19-cutaneou s-manifestations-and-issues-related-to-dermatologic-care (accessed on January 20, 2023).