Dermatology Covid-19 Registry

Thank you for agreeing to take part in this important effort to understand dermatologic manifestations of the COVID-19 virus. This survey is for all health care professionals taking care of a) COVID-19 patients that develop dermatologic manifestations, b) dermatology patients with an existing condition that then develop COVID-19, or c) dermatologic reactions to a COVID-19 vaccine

The case report form should take about 5-7 minutes to complete. Patient identifiers such as name or date of birth will not be collected. All de-identified information will be kept strictly confidential and will only be shared with researchers compiling information. Data will be stored on a secure Redcap server at Massachusetts General Hospital (Partners Healthcare).

The success of this collaborative effort depends on active participation by our international healthcare community to obtain accurate and reliable information. This registry is for healthcare professionals from all countries. We ask that you share this site with your colleagues and encourage them to report any cases of COVID-19 related dermatoses. Even if you have already submitted your case to a journal, please enter a summary of the case here so we can get an accurate understanding of the range of Dermatologic manifestations from Covid-19.

This form has been reviewed by the Massachusetts General Hospital (Partners Healthcare) institutional review board.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

First name (given name) of reporter

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Last name (family name) of reporter

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Email address of reporter (institution email preferred)

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Professional title of reporter

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Dermatologist

Other Physician

Podiatrist

Physician Assistant

Nurse Practitioner

Nurse

Other

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Other professional title:

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Hospital or clinic name

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Hospital or clinic country

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Other country:

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Hospital or clinic state

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What is the patient's age in years?

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Patient's country of residence

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Other:

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Patient's U.S. state of residence

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What was the patient's assigned sex at birth?

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Female

Male

Unknown

Other

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Other assigned sex:

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Patient's race/ethnicity

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White

Black - African

Afro - Caribbean

African American

American Indian / Alaska Native

Asian American

Asian-Chinese

South Asian (India, Pakistan, Sri Lanka, Nepal, Bhutan, Bangladesh)

Asian-other (Korea, China, north of Huai River)

Japanese

Hispanic or Latino

Native Hawaiian / Pacific Islander

Unknown

Other

Other race/ethnicity:

* must provide value

Is the patient hispanic/latino?

* must provide value

Yes

Don't know

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Did the patient receive a COVID-19 vaccine?

* must provide value

Yes

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In which month did the patient receive the first dose of the COVID-19 vaccine?

* must provide value

In which year did the patient receive the first dose of the COVID-19 vaccine?

* must provide value

If administered a two-dose vaccine, did the patient receive a second dose of the COVID-19 vaccine?

(If the patient received a single-dose vaccine, e.g., Johnson & Johnson, please answer "No," even if the patient was subsequently given a booster dose after their original J&J vaccine.)

* must provide value

Yes

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In which month did the patient receive the second dose of the COVID-19 vaccine?

* must provide value

In which year did the patient receive the second dose of the COVID-19 vaccine?

* must provide value

Did the patient receive a first booster dose of the COVID-19 vaccine?

(For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose. For single-dose J&J, the first booster is the patient's second dose.)

* must provide value

Yes

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In which month did the patient receive the first booster dose of the COVID-19 vaccine?

* must provide value

In which year did the patient receive the first booster dose of the COVID-19 vaccine?

* must provide value

Why did the patient not receive a second vaccine dose in their original vaccine series?

* must provide value

The patient is planning on receiving the second dose at the appropriate time interval which has not yet occurred

Vaccine only scheduled for one dose (for example, J&J)

Second dose held due to side effects from first vaccine dose

Other

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Why was the second vaccine dose held?

* must provide value

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What was the other reason the patient did not receive the second vaccine dose?

Which brand of vaccine did the patient receive for their first dose?

* must provide value

Which brand of vaccine did the patient receive for the second dose of their original vaccine series?

* must provide value

Which brand of vaccine did the patient receive for the first booster dose?

(For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose. For single-dose J&J, the first booster is the patient's second dose.)

* must provide value

Which other brand of the vaccine did the patient receive?

Are you reporting a dermatologic manifestation of a COVID-19 vaccine?

* must provide value

Yes

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Did this patient previously have COVID-19 prior to receiving the vaccine?

* must provide value

Yes, SARS-CoV-2 PCR positive

Yes, SARS-CoV-2 antibody positive

Yes, SARS-CoV-2 antigen positive

Yes, laboratory positive but test type unknown

Yes, clinical suspicion only

Don't Know

Considering the patient's original vaccine series only (i.e., first two doses only for Moderna/Pfizer/AstraZeneca, first dose only for J&J), did the patient develop a cutaneous reaction to the first, second, or both vaccine doses?

If reporting for a J&J original vaccine series reaction, please select the"first dose" option.

If reporting a booster shot reaction only, and the patient did not develop a cutaneous reaction to the original vaccine series, please select "N/A."

* must provide value

First dose

Second dose

Both doses (two separate reactions)

N/A

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Was the cutaneous reaction for the first and second vaccine doses the same?

* must provide value

Yes

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Was the cutaneous reaction for the first and second vaccine doses of the same magnitude?

* must provide value

Larger reaction for the first dose

Larger reaction for the second dose

Similar reactions for both doses

Don't know

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Did the patient develop a cutaneous reaction to the first booster dose?

(For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose. For single-dose J&J, the first booster is the patient's second dose.)

* must provide value

Yes

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Was the cutaneous reaction for the first dose of the original vaccine series and the first booster vaccine dose the same?

(The first dose refers to the first dose of the patient's original vaccine series. For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose. For single-dose J&J, the first booster is the patient's second dose.)

* must provide value

Yes

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If the patient was administered a two-dose vaccine, was the cutaneous reaction for the second dose of the original vaccine series and first booster vaccine dose the same?

(The second dose refers to the second dose of the patient's original vaccine series if administered a two-dose vaccine. For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose.)

Yes

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Was the cutaneous reaction for all vaccine doses (including booster doses) the same?

* must provide value

Yes

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Considering all vaccine doses administered to the patient, which dose resulted in a cutaneous reaction of the largest magnitude?

If reporting for only one dose, select an answer with that dose as the largest.

The first dose refers to the first dose of the patient's original vaccine series.
The second dose refers to the second dose of the patient's original vaccine series if a two-dose vaccine was administered (e.g., Moderna).
The third dose, in this question only, refers to the first booster dose, regardless of the original vaccine series (single-dose or two-dose).

* must provide value

Largest reaction for the first dose

Largest reaction for the second dose

Largest reaction for the third dose

Similar reactions for all doses

Don't know

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* must provide value

Largest reaction for the first dose, as part of the original vaccine series

Largest reaction for the second dose, as part of the original vaccine series (select for two-dose vaccines only)

Largest reaction for the first booster dose, i.e., the third dose if the patient was administered a two-dose vaccine (e.g., Moderna) OR the second dose if administered a single-dose vaccine (e.g., J&J)

Similar reactions for all doses

Don't know

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How many days after the first dose of the COVID-19 vaccine did the patient develop a skin finding?

* must provide value

If the patient was administered a two-dose vaccine, how many days after the second dose of the COVID-19 vaccine did the patient develop a skin finding?

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop a skin finding?

(For two-dose vaccines such as Moderna/Pfizer, the first booster dose is the patient's third dose. For single-dose J&J, the first booster is the patient's second dose.)

* must provide value

For how many days total did the patient have or has continued to have the reported dermatologic finding to the first vaccine dose?

* must provide value

For how many days total did the patient have or has continued to have the reported dermatologic finding to the second vaccine dose?

* must provide value

For how many days total did the patient have or has continued to have the reported dermatologic finding to the first booster vaccine dose?

* must provide value

Please review the following images to aid in selecting the morphology of the vaccine cutaneous reaction

What were the observed skin symptoms after the first vaccine dose? Select all that apply

* must provide value

Local site reaction: swelling

Local site reaction: redness

Local site reaction: pain

Morbilliform rash

Vesicular rash

Contact dermatitis

Delayed hypersensitivity - local at vaccine site

Delayed hypersensitivity - larger than vaccine site

Urticaria (beyond injection site, including generalized)

Angioedema

Pruritus (itching)

Vasculitis

Alopecia

Filler reaction

Reaction in breast-fed infant

Livedo reticularis

Pernio/chilblains ("Covid toes")

Erythromelalgia (hands, feet, or face with pain/redness/swelling)

Erythema multiforme

Pityriasis rosea

Petechiae

Bullous disease

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome

Acute generalized exanthematous pustulosis (AGEP)

Zoster (VZV)

New dermatologic condition (ie. dermatomyositis, lupus, scleroderma, pityriasis rosea, lichen planus, pemphigus, etc)

Flare of existing dermatologic condition (ie. psoriasis, atopic dermatitis, lupus, flare of chronic urticaria, HSV reactivation etc)

Other

What were the other skin symptoms?

* must provide value

What is the age in months of the breastfed infant?

Please confirm above that all patient characteristics are for the person who received the COVID-19 vaccine (ie. the person breastfeeding)

* must provide value

What is the sex of the infant?

* must provide value

Female

Male

Unknown

Other

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What was the morphology of the infant's rash? Which body sites did it affect?

* must provide value

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Do you know how many days after the patient received the first dose of the COVID-19 vaccine the skin finding started?

* must provide value

Yes

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How many days after the first dose of the COVID-19 vaccine did the patient develop the local site reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop the morbilliform rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop the vesicular rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop contact dermatitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop the delayed hypersensitivity rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop the erythromelalgia?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop the urticarial rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop angioedema?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop pruritius (itching)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop vasculitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop alopecia?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop a filler reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient's infant develop a rash in a breast-fed infant?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop livedo reticularis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop pernio/chilblains?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop erythema multiforme?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop pityriasis rosea?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop petechiae?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop bullous disease?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop DRESS syndrome?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop AGEP?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop Zoster (VZV)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop a new dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop a flare of an existing dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first dose of the COVID-19 vaccine did the patient develop an "other" dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

Is the patient's dermatologic reaction to the first vaccine dose still present at the time of this report?

* must provide value

Yes

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For how many days total did the patient have or has continued to have the local site reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the morbilliform rash to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vesicular rash to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the contact dermatitis to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the delayed hypersensitivity to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythromelalgia to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the urticarial rash to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the angioedema to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pruritus (itching) to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vasculitis to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the alopecia to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the filler reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the dermatologic reaction in a breastfed infant to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the livedo reticularis to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pernio/chilblains reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythema multiforme reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pityriasis rosea to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the petechiae to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the bullous disease to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the DRESS reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the AGEP reaction to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have Zoster (VZV) to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the new dermatologic condition to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the flare of the existing dermatologic condition to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the "Other" dermatologic condition to the first vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

Which new dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other new dermatologic condition?

Which flare of an existing dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Chronic urticaria

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other dermatologic condition?

Where on the patient's body did the dermatologic reaction to the first vaccine dose occur?

* must provide value

Face

Oral mucosa

Nails

Hair

Head

Neck

Vaccinated arm

Non-vaccinated arm

Hand

Chest

Abdomen

Back

Genitals

Buttocks

Leg

Foot

Did the patient develop any systemic symptoms after the first Covid-19 vaccine?

* must provide value

Yes

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What were the observed systemic symptoms after the first dose? Select all that apply

* must provide value

Anaphylaxis (>1 of urticaria, throat or tongue swelling, shortness of breath, vomiting, lightheadedness, low blood pressure)

Fever

Chills

Headache

Myalgia (localized to injection arm or generalized)

Arthralgia

Fatigue

Nausea

Vomiting

Diarrhea

Lymphadenopathy

Bells palsy

Syncope/Vasovagal

Other

What were the other systemic symptoms?

* must provide value

Please review the following images to aid in selecting the morphology of the cutaneous vaccine reaction

What were the observed skin symptoms after the second vaccine dose? Select all that apply

* must provide value

Local site reaction: swelling

Local site reaction: redness

Local site reaction: pain

Morbilliform rash

Vesicular rash

Contact dermatitis

Delayed hypersensitivity - local at vaccine site

Delayed hypersensitivity - larger than vaccine site

Urticaria (beyond injection site, including generalized)

Angioedema

Pruritus (itching)

Vasculitis

Alopecia

Filler reaction

Reaction in breast-fed infant

Livedo reticularis

Pernio/chilblains ("Covid toes")

Erythromelalgia (hands, feet, or face with pain/redness/swelling)

Erythema multiforme

Pityriasis rosea

Petechiae

Bullous disease

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome

Acute generalized exanthematous pustulosis (AGEP)

Zoster (VZV)

New dermatologic condition (ie. dermatomyositis, lupus, scleroderma, pityriasis rosea, lichen planus, pemphigus, etc)

Flare of existing dermatologic condition (ie. psoriasis, atopic dermatitis, lupus, flare of chronic urticaria, HSV reactivation etc)

Other

What were the other skin symptoms?

* must provide value

Do you know how many days after the patient received the second dose of the COVID-19 vaccine the skin finding started?

* must provide value

Yes

reset

How many days after the second dose of the COVID-19 vaccine did the patient develop the local site reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop the morbilliform rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop the vesicular rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop contact dermatitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop the delayed hypersensitivity rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop the erythromelalgia rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop the urticarial rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop angioedema?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop pruritius (itching)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop vasculitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop alopecia?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop a filler reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient's infant develop a skin rash in a breast-fed infant?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop livedo reticularis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop pernio/chilblains?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop erythema multiforme?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop pityriasis rosea?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop petechiae?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop bullous disease?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop DRESS syndrome?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop AGEP?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop Zoster (VZV)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop a new dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop a flare of an existing dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the second dose of the COVID-19 vaccine did the patient develop an "other" dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

Is the patient's dermatologic reaction to the second vaccine dose still present at the time of this report?

* must provide value

Yes

reset

For how many days total did the patient have or has continued to have the local site reaction to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the morbilliform rash to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vesicular rash to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the contact dermatitis to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the delayed hypersensitivity to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythromelalgia to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the urticarial rash to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the angioedema to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pruritus (itching) to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vasculitis to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the alopecia to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the filler reaction to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the dermatologic reaction in a breastfed infant to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the livedo reticularis to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pernio/chilblains reaction to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythema multiforme to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have pityriasis rosea to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the AGEP reaction to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the DRESS reaction to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the bullous disease to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the petechiae to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the Zoster (VZV) to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the new dermatologic condition to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the flare of the existing dermatologic condition to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the "Other" dermatologic condition to the second vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

Which new dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other new dermatologic condition?

Which flare of an existing dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Chronic urticaria

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other dermatologic condition?

Where on the patient's body did the dermatologic reaction to the second vaccine dose occur?

* must provide value

Face

Oral mucosa

Nails

Hair

Head

Neck

Vaccinated arm

Non-vaccinated arm

Hand

Chest

Abdomen

Back

Genitals

Buttocks

Leg

Foot

Did the patient develop any systemic symptoms after the second Covid-19 vaccine?

* must provide value

Yes

reset

What were the observed systemic symptoms after the second dose? Select all that apply

* must provide value

Anaphylaxis (>1 of urticaria, throat or tongue swelling, shortness of breath, vomiting, lightheadedness, low blood pressure)

Fever

Chills

Headache

Myalgia (localized to injection arm or generalized)

Arthralgia

Fatigue

Nausea

Vomiting

Diarrhea

Lymphadenopathy

Bells palsy

Syncope/Vasovagal

Other

What were the other systemic symptoms?

* must provide value

Did the patient develop any systemic symptoms after the third Covid-19 vaccine?

* must provide value

Yes

reset

What were the observed systemic symptoms after the first booster dose? Select all that apply

* must provide value

Anaphylaxis (>1 of urticaria, throat or tongue swelling, shortness of breath, vomiting, lightheadedness, low blood pressure)

Fever

Chills

Headache

Myalgia (localized to injection arm or generalized)

Arthralgia

Fatigue

Nausea

Vomiting

Diarrhea

Lymphadenopathy

Bells palsy

Syncope/Vasovagal

Other

What were the other systemic symptoms?

* must provide value

Please review the following images to aid in selecting the morphology of the cutaneous vaccine reaction

Do you know how many days after the patient received the first booster dose of the COVID-19 vaccine the skin finding started?

* must provide value

Yes

reset

What were the observed skin symptoms after the first booster vaccine dose? Select all that apply

* must provide value

Local site reaction: swelling

Local site reaction: redness

Local site reaction: pain

Morbilliform rash

Vesicular rash

Contact dermatitis

Delayed hypersensitivity - local at vaccine site

Delayed hypersensitivity - larger than vaccine site

Urticaria (beyond injection site, including generalized)

Angioedema

Pruritus (itching)

Vasculitis

Alopecia

Filler reaction

Reaction in breast-fed infant

Livedo reticularis

Pernio/chilblains ("Covid toes")

Erythromelalgia (hands, feet, or face with pain/redness/swelling)

Erythema multiforme

Pityriasis rosea

Petechiae

Bullous disease

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome

Acute generalized exanthematous pustulosis (AGEP)

Zoster (VZV)

New dermatologic condition (ie. dermatomyositis, lupus, scleroderma, pityriasis rosea, lichen planus, pemphigus, etc)

Flare of existing dermatologic condition (ie. psoriasis, atopic dermatitis, lupus, flare of chronic urticaria, HSV reactivation etc)

Other

What were the other skin symptoms?

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the local site reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the morbilliform rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the vesicular rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop contact dermatitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the delayed hypersensitivity rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the erythromelalgia rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop the urticarial rash?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop angioedema?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop pruritius (itching)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop vasculitis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop alopecia?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop a filler reaction?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient's infant develop a skin rash in a breast-fed infant?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop livedo reticularis?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop pernio/chilblains?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop erythema multiforme?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop pityriasis rosea?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop petechiae?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop bullous disease?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop DRESS syndrome?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop AGEP?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop Zoster (VZV)?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop a new dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop a flare of an existing dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

How many days after the first booster dose of the COVID-19 vaccine did the patient develop an "other" dermatologic condition?

Please enter "0" days if the reaction occurred < 24 hours after vaccine administration

* must provide value

Is the patient's dermatologic reaction to the first booster vaccine dose still present at the time of this report?

* must provide value

Yes

reset

For how many days total did the patient have or has continued to have the local site reaction to the first booster vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the morbilliform rash to the first booster vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vesicular rash to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the contact dermatitis to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the delayed hypersensitivity to the first booster vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythromelalgia to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the urticarial rash to the first booster vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the angioedema to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pruritus (itching) to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the vasculitis to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the filler reaction to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the alopecia to the first booster vaccine dose?

If the dermatologic conditon is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the dermatologic reaction in a breastfed infant to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the pernio/chilblains reaction to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the livedo reticularis to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the petechiae to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have pityriasis rosea to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the erythema multiforme to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the AGEP reaction to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the DRESS reaction to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the bullous disease to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the Zoster (VZV) to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the new dermatologic condition to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the flare of the existing dermatologic condition to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

For how many days total did the patient have or has continued to have the "Other" dermatologic condition to the first booster vaccine dose?

If the dermatologic condition is ongoing please report the duration up to the time of this report

* must provide value

Which new dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other new dermatologic condition?

Which flare of an existing dermatologic condition did the patient develop? Select all that apply

* must provide value

Alopecia areata

Atopic dermatitis

Bullous pemphigoid

Contact dermatitis

Chronic urticaria

Cutaneous vasculitis

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Erythema nodosum

Granuloma annulare

Herpes simplex (HSV)

Herpes zoster (VZV)

Hidradenitis suppurativa

Lichen planus

Lichen sclerosus

Linear IgA disease

Lupus - systemic lupus erythematosus

Lupus - discoid lupus erythematosus

Lupus - other cutaneous lupus

Morphea

Pemphigus vulgaris

Pityriasis rosea

Psoriasis

Sarcoidosis

Scleroderma

Vitiligo

Other

What was the other dermatologic condition?

Where on the patient's body did the dermatologic reaction to the first booster vaccine dose occur?

* must provide value

Face

Oral mucosa

Nails

Hair

Head

Neck

Vaccinated arm

Non-vaccinated arm

Hand

Chest

Abdomen

Back

Genitals

Buttocks

Leg

Foot

Do you have a photo of the skin finding that you would be willing to share?

* must provide value

Yes

reset

Was a biopsy of the vaccine dermatologic reaction performed?

* must provide value

Biopsy not performed

Yes biopsy performed for vaccine dermatologic reaction to first dose

Yes biopsy performed for vaccine dermatologic reaction to second dose

Yes biopsy performed for vaccine dermatologic reaction to first and second doses

Yes biopsy performed for vaccine dermatologic reaction to third dose

Don't know

reset

Please enter the biopsy report:

Expand

Was the patient given treatment for the vaccine skin reaction?

* must provide value

No treatments given

Oral anti-histamine

Epinephrine injection

Topical steroids

Systemic steroids

NSAID

Acetaminophen

Antibiotics

Valacyclovir/Acyclovir

Lisinopril

Don't Know

Other

What was the other treatment for the vaccine skin reaction?

* must provide value

Does this patient have a history of a vaccine allergic reaction?

* must provide value

Yes - Local site reaction

Yes - Anaphylaxis

Yes - Urticaria

Yes - Other Reaction

Don't know

Please describe the prior vaccine allergic reaction:

* must provide value

Does this patient have a history of an injectable medication allergic reaction?

* must provide value

Yes - Local site reaction

Yes - Anaphylaxis

Yes - Urticaria

Yes - Other Reaction

Don't know

Please describe the prior injectable medication allergic reaction:

* must provide value

Did the patient previously receive a Zoster vaccine?

* must provide value

Yes - Zoster vaccine live (ZVL, Zostavax)

Yes - Recombinant zoster vaccine (RZV, Shingrix)

Yes - Both Zostavax and Shingrix

Yes - Unknown brand

Don't know

reset

Was the patient's Varicella Zoster Virus (VZV) laboratory confirmed?

* must provide value

Yes

reset

Which Varicella Zoster Virus (VZV) laboratory test was positive?

Was the patient's Herpes simplex virus (HSV) laboratory confirmed?

* must provide value

Yes

reset

Which Herpes simplex virus (HSV) laboratory test was positive?

[Optional] Please use this space to describe the dermatology-related COVID-19 vaccine reaction further if not fully captured in the fields above

Expand

Did the patient have new skin, nail, hair, mucous membrane or other dermatologic changes in the setting of possible or confirmed Covid-19?

* must provide value

Yes

reset

When did this patient develop a COVID-19 dermatologic manifestation in relation to receiving a COVID-19 vaccine?

* must provide value

Vaccine occurred after COVID-19 dermatologic manifestation began

Vaccine occurred before COVID-19 dermatologic manifestation began

Vaccine occurred at the same time as the COVID-19 dermatologic manifestation

Don't know

reset

Do you have a photo of the dermatologic condition?

* must provide value

Yes

reset

Was a biopsy of the Covid-19 dermatologic manifestation obtained?

* must provide value

Yes

reset

What did the pathology report show? Please put "NA" if the report is unavailable.

* must provide value

Expand

Did the patient have telogen effluvium?

Yes

reset

Which site did the edema involve? Mark all that apply.

* must provide value

Periorbital edema

Other facial edema

Upper extremity edema

Lower extremity edema

Genital edema

Other

Which dermatologic condition(s) were associated with the Covid-19 infection? Mark all that apply.

* must provide value

Skin changes (rash, pernio/chilblains, skin pain/burning, etc)

Edema

Mucous membrane changes

Hair changes

Nail changes

Other dermatologic change

Other site of edema:

* must provide value

Which mucous membranes were involved? Mark all that apply.

* must provide value

Oral mucosa

Nasal mucosa

Ocular mucosa

Vaginal mucosa

Urethral mucosa

Anal mucosa

What were the ocular findings? Mark all that apply.

* must provide value

Yes eye findings but unsure of categorization

Conjunctivitis (conjunctival inflammation)

Chemosis (swelling of conjunctiva)

Secretions (eye discharge)

Conjunctival hyperemia (dilation and redness of conjunctival vessels)

Epiphora (excessive eye watering)

Other

Other ocular finding:

* must provide value

Expand

Please describe the observed mucous membrane changes. In your clinical opinion, were the mucous membrane changes related to Covid-19 itself, medications the patient received, or another medical condition?

* must provide value

Expand

Please describe the observed hair changes. In your clinical opinion, were the hair changes related to Covid-19 itself, medications the patient received, or another medical condition?

* must provide value

Expand

Please describe the observed nail changes. In your clinical opinion, were the nail changes related to Covid-19 itself, medications the patient received, or another medical condition?

* must provide value

Expand

When did the skin findings start in relation to Covid symptoms?

* must provide value

Before Covid symptoms started

After Covid symptoms started

At the same time as Covid symptoms

Patient never developed any other Covid symptoms except skin findings

Don't know

reset

Please describe any other dermatologic changes. In your clinical opinion, were the changes related to Covid-19 itself, medications the patient received, or another medical condition?

* must provide value

Expand

Do you know how many days before Covid symptoms started the skin lesion developed?

* must provide value

Yes

reset

How many days before Covid symptoms started did the rash develop?

* must provide value

Do you know how many days after Covid symptoms started the skin lesion developed?

* must provide value

Yes

reset

How many days after Covid symptoms started did the rash develop?

* must provide value

When did the skin findings start in relation to Covid treatment?

* must provide value

Before Covid treatment started

After Covid treatment started

At the same time Covid treatment started

Not Applicable

Don't know

reset

Have the patient's skin findings resolved at the time of this report?

* must provide value

Yes

Don't know

reset

For how many days did the patient have the skin findings?

* must provide value

Do you know how long the patient had the skin findings?

* must provide value

Yes

reset

Did the patient have any skin symptoms?

* must provide value

Asymptomatic

Pain or Burning

Pruritus

Cold intolerance

Don't know

What is the morphology of the skin findings? Mark all that apply.

Please see below for example images of rash morphology.

* must provide value

Morbilliform rash

Urticarial eruption

Dengue-like rash

Vesicular eruption

Livedo reticularis-like rash

Retiform purpura

Grovers-like rash

Papulosquamous rash

Bullous eruption

Erythroderma

Pustular rash

Macular erythema

Acrocyanosis

Pernio (Chilblains)

Acral desquamation

Pressure injury

Palpable purpura / vasculitis

Petechiae

Erythema nodosum

Acneiform

Miliaria rubra

Livedo racemosa

Kawasaki-like/Multi-system inflammatory syndrome (MIS-C)

Multisystem Inflammatory Syndrome in Adults (MIS-A)

Not applicable

Don't know

Other

Please view the images below to assist you in determining rash morphology.

(Note: These are morphology examples and are NOT pictures of COVID-19 patients. Permission to use these photos granted by VisualDX)

Other morphology

* must provide value

Expand

Does this patient have a history of pernio/chilblains prior to the start of the Covid-19 pandemic?

* must provide value

Yes

Don't know

reset

Which type of pernio/chilblains case are you reporting?

* must provide value

First instance of pernio for patient

Pernio that started with an initial Covid-19 wave, resolved, and then recurred

Don't know

reset

In which month and year did the pernio lesions first start?

* must provide value

In which month and year did the pernio lesions start again?

* must provide value

In which month and year did the pernio lesions clear?

* must provide value

Was the pressure ulcer likely due to the patient being positioned prone?

* must provide value

Yes

Don't know

reset

What areas of the body do the skin findings involve? Mark all that apply.

* must provide value

Face

Head

Neck

Chest

Abdomen

Back

Arm

Hand

Genitals

Buttocks

Leg

Foot

Entire body

Other

Were there any additional labs obtained for this COVID-19 related dermatologic condition that you would like to report?

* must provide value

Yes

reset

Other area of the body:

* must provide value

Less than reference range

Within reference range

Higher than reference range

Don't know

Hemoglobin

* must provide value

reset

Please check the labs that were obtained for the COVID-19 dermatologic condition that you would like to report

* must provide value

Hemoglobin

White blood cell count

Platelet count

Antinuclear antibodies (ANA)

Rheumatoid factor (RF)

Cold agglutinins

Cryoglobulins

Complement (C3/C4/CH50)

C-Reactive Protein (CRP)

Erythrocyte sedimentation rate (ESR)

D-Dimer

Fibrinogen

Anticardiolipin antibodies (aCL)

Anti-beta2-glycoprotein (GP) antibodies

Lupus anticoagulant (LA)

Other

What is the other lab and lab value you would like to report?

* must provide value

Less than reference range

Within reference range

Higher than reference range

Don't know

White blood cell count

* must provide value

reset

Platelet count

* must provide value

reset

Antinuclear antibodies (ANA)

* must provide value

reset

Rheumatoid factor (RF)

* must provide value

reset

Cold agglutinins

* must provide value

reset

Cryoglobulins

* must provide value

reset

Complement (C3/C4/CH50)

* must provide value

reset

C-Reactive Protein (CRP)

* must provide value

reset

Erythrocyte sedimentation rate (ESR)

* must provide value

reset

D-Dimer

* must provide value

reset

Fibrinogen

* must provide value

reset

Anticardiolipin antibodies

* must provide value

reset

Anti-beta2-glycoprotein

* must provide value

reset

Lupus anticoagulant (LA)

* must provide value

reset

In your clinical opinion, what is the likely etiology of the dermatologic findings?

* must provide value

Likely related to Covid virus itself

Likely related to a drug given for Covid treatment

Likely related to a drug given for a condition other than Covid

Likely related to another virus

Likely related to a post-viral rash

Unsure

Other

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Other etiology of the skin findings:

* must provide value

Expand

Would you be willing to be contacted about this patient if we need further clarification about this case?

* must provide value

Yes

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(Optional): Please describe the dermatology-related Covid-19 case in 1-5 sentences:

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Does this patient have a pre-existing dermatologic condition?

* must provide value

Yes

Unknown

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What is the patient's primary existing dermatologic condition?

* must provide value

Other primary existing dermatologic condition:

* must provide value

What was the symptom activity of the patient's dermatologic disease at the time of Covid-19 symptom onset (or Covid-19 diagnosis if asymptomatic)?

* must provide value

Remission

Minimal or low disease activity

Moderate disease activity

Severe or high disease activity

Unknown

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Did the patient's dermatologic disease change at the time of Covid-19 symptom onset (or Covid-19 diagnosis if asymptomatic)?

* must provide value

Worsened

Improved

Stayed the same

Unknown

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Which medications is the patient taking for their dermatologic condition? Mark all that apply.

* must provide value

None

Antimalarials (including hydroxychloroquine, chloroquine)

Azathioprine

CD-20 inhibitors (including rituximab, ofatumumab)

Cyclophosphamide

Cyclosporine

Doxycycline

Glucocorticoids (prednisone, methylprednisolone)

IL-1 inhibitors (including anakinra, canakinumab, rilonacept)

IL-12/23 inhibitors (including ustekinemab)

IL-23 inhibitors (including guselkumab, tildrakizumab, risankizumab)

IL-17 inhibitors (including secukinumab, ixekizumab)

IL-6 inhibitors (including tocilizumab, sarilumab)

Isotretinoin

IVIG

JAK inhibitors (including tofacitinib, baricitinib, upadacitinib)

Leflunomide

Methotrexate

Minocycline

Mycophenolate mofetil / mycophenolic acid

Spironolactone

Sulfasalazine

Tacrolimus (topical)

Tacrolimus (oral)

Thalidomide / lenalidomide

TNF-inhibitors (including infliximab, etanercept, adalimumab, golimumab, certolizumab, and biosimilars)

Topical steroid class II (ex. betamethasone, mometasone)

Topical steroids class I (ex. clobetasol)

Unknown

Other

Other medication for their dermatologic condition prior to Covid-19 diagnosis:

* must provide value

In the 14 days before onset of Covid-19 illness did the patient have any of the following contacts?

* must provide value

None (community acquired)

Close contact with a probable case of COVID-19 infection

Close contact with a laboratory confirmed case of COVID-19 infection

Presence in a healthcare facility where COVID-19 infections have been managed

Unknown

Other

Other Covid-19 contacts:

* must provide value

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Do you know the date of the patient's COVID-19 diagnosis?

* must provide value

Yes

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What was the date of the patient's COVID-19 diagnosis?

* must provide value

M-D-Y

What kind of COVID-19 testing was performed? Please mark all that apply, including both antibody and PCR testing

* must provide value

Presumptive diagnosis based on symptoms only

PCR positive

Antibody positive

PCR negative

Antibody negative

Metagenomic testing

Laboratory assay positive, type unknown

Laboratory assay negative, type unknown

Unknown if a COVID-19 test was performed

Other

Which of the following antibodies were positive?

* must provide value

Positive, but unknown which antibody

IgM positive and IgG positive

IgM positive, IgG negative

IgM negative, IgG positive

IgM positive, IgG unknown

IgM unknown, IgG positive

Other

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Other positive antibody

* must provide value

What type of antibody testing was performed?

* must provide value

Abbott Laboratories

Becton Dickinson

Roche

DiaSorin

EUROIMMUN US Inc.

Wadsworth Center, New York State Department of Health

Bio-Rad Laboratories, Inc

Ortho-Clinical Diagnostics, Inc

Autobio Diagnostics Co. Ltd.

Chembio Diagnostic System, Inc

Cellex Inc.

Don't know

Other

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Which of the following antibodies were negative?

* must provide value

Negative, but unknown which antibody

IgM negative and IgG negative

IgM negative, IgG unknown

IgM unknown, IgG negative

Other

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Other antibody testing type:

* must provide value

Other negative antibody

* must provide value

Other type of Covid-19 diagnosis:

* must provide value

Are any of the following laboratory tests pending? (if yes, we may contact you about the results at a later date)

None

COVID PCR testing

COVID antibody testing

Did the patient have any non-dermatologic COVID-19 symptoms?

* must provide value

None (Asymptomatic)

Fever

Chills

Headache

Sore throat

Cough

Shortness of breath

Arthralgia

Myalgia

Chest pain

Abdominal pain

Diarrhea, vomiting or nausea

Rhinorrhea

Irritability/confusion

Malaise

Anosmia

Dysgeusia

Don't know

Other

Other non-dermatologic Covid-19 symptom:

* must provide value

Do you know how much time elapsed (in days) between the patient's first non-dermatologic COVID-19 symptom and their PCR test?

* must provide value

Yes

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How many days after the non-dermatologic COVID-19 symptoms first started was PCR testing performed?

* must provide value

Do you know how much time elapsed (in days) between the patient's first dermatologic COVID-19 symptom and their PCR test?

* must provide value

Yes

reset

How many days after the dermatologic COVID-19 symptoms first started was PCR testing performed?

* must provide value

Do you know how much time elapsed (in days) between the patient's first non-dermatologic COVID-19 symptom and their antibody test?

* must provide value

Yes

reset

How many days after the non-dermatologic COVID-19 symptoms first started was antibody testing performed?

* must provide value

Do you know how much time elapsed (in days) between the patient's first dermatologic COVID-19 symptom and their antibody test?

* must provide value

Yes

reset

How many days after the dermatologic COVID-19 symptoms first started was antibody testing performed?

* must provide value

Was any COVID-19 specific treatment given? Please mark all that apply.

* must provide value

No treatment except supportive care

Antibiotics

Remdesivir

Lopinavir/ritonavir

Anti-malarials (e.g. chloroquine, hydroxychloroquine)

IL-6 inhibitors (e.g. tocilizumab, sarilumab, siltuximab)

Bevacizumab

JAK inhibitors (e.g. tofacitinib, baricitinib, upadacitinib)

Serpin inhibitors

Ciclesonide

Glucocorticoids

IVIG

Plasma from recovered patients

Interferon

Don't know

Other

Which antibiotic was given? Please mark all that apply.

* must provide value

Azithromycin

Doxycycline

Clarithromycin

Amoxicillin

Levofloxacin

Moxifloxacin

Ciprofloxacin

Ceftriaxone

Amoxicillin-clavulanate

Piperacillin-tazobactam

Cefepime

Ceftazidime

Meropenem

Imipenem

Vancomycin

Linezolid

Unknown antibiotic

Other antibiotic

Other:

* must provide value

What was the maximum level of care required during COIVD-19 infection?

* must provide value

Did not require supplemental oxygen

Required supplemental oxygen

Required non-invasive ventilation or high flow oxygen devices

Required invasive mechanical ventilation or ECMO

Ventilation required, but type unknown

Don't know

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Was the patient hospitalized during COVID-19 illness?

* must provide value

Yes

Don't know

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Were there any COVID-19 complications?

* must provide value

No known complications

Acute Respiratory Distress Syndrome or ARDS

Sepsis

Myocarditis or new heart failure

Concomitant or secondary infection (e.g. Influenza)

Acute Kidney Injury

Thrombotic event, unknown origin

DVT

Thrombotic stroke

Pulmonary embolism

Don't know

Other serious complication

Other serious complication:

* must provide value

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Did patient die of COVID-19 or other complications caused by or contributed to by COVID-19?

* must provide value

Yes

Don't know

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Have the patient's COVID-19 symptoms resolved at the time of this report?

* must provide value

Yes

Don't know

reset

Do you know approximately how many days the patient was symptomatic with COVID-19?

* must provide value

Yes

reset

Approximately how many days passed from COVID-19 symptom onset to resolution?

* must provide value

Patient's smoking status

* must provide value

Current smoker

Former smoker

Never smoked

Unknown smoking status

reset

Does the patient have any of the following other medical conditions? Mark all that apply.

* must provide value

None

Interstitial lung disease (e.g. NSIP, UIP, IPF)

Obstructive lung disease (COPD/asthma)

Other lung disease

Diabetes

Morbid obesity (BMI 40+)

Hypertension

Cardiovascular disease (coronary artery disease, congestive heart failure)

Pulmonary hypertension

Chronic renal insufficiency or end stage renal disease

Cancer

Organ transplant recipient

Immunodeficiency

Inflammatory bowel disease

Liver disease

Chronic neurological or neuromuscular disease

Trisomy 21

Psychiatric condition (e.g., schizophrenia, bipolar disorder)

Pregnancy

Post-partum (< 6 weeks)

Rheumatologic disease

Don't know

Other

Other co-morbid medical condition:

* must provide value

Expand

Has this patient case been entered in any other COVID-related registry?

* must provide value

None

PsoProtect

SECURE-Psoriasis

Atopic Dermatitis SECURE-AD Registry

Global Hidradenitis Suppurativa COVID-19 Registry

SECURE Alopecia

Vitiligo Group Registry

The French Society of Dermatology's Dermatologic Manifestations of COVID-19 Registry

PeDRA pediatric dermatology COVID-19 registry

Thank you for entering this patient with psoriasis! Please submit your case here, and then if you are able, please additionally consider entering this case into the psoriasis registry, as detailed below:

Psoriasis (PsoPROTECT registry)

www.psoprotect.org

PsoPROTECT is a new global registry established to assess outcomes of COVID-19 in patients with psoriasis. It operates in collaboration with other dermatology COVID registries and international organisations including the International Psoriasis Council, International Federation of Psoriasis Associations, Global Psoriasis Atlas, ILDS, ESDR, EADV, SPIN and EDF. Entering cases of psoriasis with suspected or confirmed COVID-19 via the simple online case report forms is both quick and easy and can be done during a virtual consultation. All data are de-identified. The information provided will rapidly improve our understanding of how factors such as systemic immunomodulatory therapies, comorbidities and disease activity affect outcomes of COVID-19 in psoriasis. Regular open-access summaries of reported cases will be provided online.

Thank you for entering this patient with atopic dermatitis! Please submit your case here, and then if you are able please additionally consider entering this case into the atopic dermatitis registry, as detailed below:

Atopic Dermatitis (SECURE-AD registry)
www.covidderm.org

The SECURE-AD registry, in collaboration with the International Society for Atopic Dermatitis, the International Eczema Council, the European Taskforce for Atopic Dermatitis, SPIN, EDEN, the EADV and the ILDS, collects de-identified data of atopic dermatitis (AD) patients with a confirmed Covid-19 infection episode. The registry collects data of all AD patients who were Covid-19 infected, including those on systemic immuno-modulatory medication. The SECURE-AD data entry platform is closely aligned to PsoProtect and other inflammatory disease registries to allow comparative analyses. Like the other registries, SECURE-AD only collects retrospectively entered anonymized patient data and has therefore been exempt from Research Ethics Committee review.

Thank you for entering this patient with hidradenitis suppurativa! Please submit your case here, and then if you are able, please additionally consider entering this case into the hidradenitis suppurativa registry, as detailed below:

https://www.hs-foundation.org/global-registry-for-hidradenitis-suppurativa-covid-19/

Thank you for entering this patient with alopecia! Please submit your case here, and then if you are able, please additionally consider entering this case into the COVID-19 alopecia registry, as detailed below:

securealopecia.covidderm.org

Thank you for entering this patient with pernio! Please submit your case here, and then if you are able, please additionally consider entering this case into the pediatric pernio registry, as detailed below:

https://pedraresearch.org/2020/04/20/covid-acral-ischemia-perniosis-in-children/