
Attuned to the Signs of Trouble
Dermatologists specialize in diseases of the skin, but can also find clues to diabetes, cancer—and even COVID-19
It’s probably safe to say that when people think of television doctors dramatically saving lives, they rarely envision dermatologists. But many experienced dermatologists have tales of doing just that. Arianne Shadi Kourosh, an HMS assistant professor of dermatology who serves as director of community health in the Department of Dermatology at Massachusetts General Hospital and is founding director of the hospital’s Multi-Ethnic Skin and Pigmentary Disorders Program, once diagnosed a woman’s endometrial cancer based on an unusual rash, and Esther Freeman, MD ’09, an HMS assistant professor of dermatology and the director of Global Health Dermatology at Mass General, caught a relatively early-stage ovarian cancer by putting together a collection of subtle symptoms including muscle weakness, a purple rash on the patient’s eyelids, and a slight “shawl sign,” or redness around the neck. “None of these things mean much separately,” Freeman says, “but together they can add up to dermatomyositis, an inflammatory autoimmune condition associated with a six-fold risk of cancer.”
The language of skin
There haven’t been many studies on skin complaints in primary care, but a 2001 retrospective review of patient charts published in the Journal of the American Academy of Dermatology found that about 36 percent of patients coming to the University of Miami’s general medicine clinic over a two-year period presented with at least one skin problem, which for 60 percent of those patients was their primary complaint. And yet, say experts, dermatology gets short shrift in medical schools. Freeman recalls receiving “exactly one day” of training before her residency.

“If more than one-third of patients have a skin care complaint and in medical school you’re only getting a few days of dermatological training,” says Freeman, “it’s a mismatch. My primary care colleagues have a hard job and have to know a lot about many different aspects of medicine, but we’re not preparing our workforce for the burden of conditions they’re going to see.”
There are “literally thousands of internal diseases, in all specialties, that can manifest on the skin,” according to Joseph Loscalzo, head of the Department of Medicine at Brigham and Women’s Hospital. Even the novel coronavirus turned out to have cutaneous manifestations.
About a month into the pandemic, doctors started noticing that some patients with COVID-19 who were otherwise asymptomatic exhibited purplish or dark red inflammation on their fingers and toes similar to what occurs with chilblains. The condition came to be known as “COVID toe.” It’s not the only cutaneous manifestation of SARS-CoV-2 , says Freeman. Others include a measleslike rash, hives, and, on the legs, a lacy pattern of lesions akin to the reddish-blue discolorations of livedo reticularis.
Freeman started an international registry to record dermatologic manifestations of COVID-19. It now has more than one thousand cases from thirty-eight countries. Data from this registry has helped identify symptoms specific to COVID-19, which, in turn, has contributed to including skin signs in testing criteria for the disease.
Freeman has presented the findings on skin signs to teams of physicians who are caring for COVID-19 patients. Following one such presentation, Freeman says, “I received an email from an infectious disease physician telling me she had a patient present with a new rash. Based on the skin findings for COVID-19, she had the patient tested—and received a positive result.”
“If recognizing these signs and testing people for the disease can help avert viral transmissions,” she adds, “well, that’s a win.”
A window within
As the body’s largest organ, skin both reflects what a person is exposed to in the environment and reveals what is happening internally. Even as it modulates and mirrors the immune system through lymphocytes, mast cells, and an immune activation system called the dendritic cell network, the skin’s ubiquitous blood vessels can also be a “window to internal disorders,” says Loscalzo.