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Abstract
A B S T R A C T
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a newly
discovered coronavirus that causes Coronavirus Disease 2019 (COVID-19). The
interaction of SARS-CoV-2 transmembrane spike (S) glycoprotein with the human
angiotensin-converting enzyme-2 (hACE2) is the primary method of virus entry to
the cell. ACE2 is a transmembrane enzyme involved in the renin-angiotensin-
aldosterone system. This enzyme plays pivotal roles in blood pressure regulations
and also electrolyte homeostasis. The expression of ACE2 in various skin cells has
been demonstrated in previous studies. Keratinocytes in the epidermis show an
exceptionally high expression of ACE2. In addition to human skin, ACE2 is also
found in animals’ tissues and were exceptionally high in cats and dogs’ skin and
eyes. This finding suggests their obscure role in COVID-19 transmission. Cutaneous
symptoms of COVID-19 in humans exist as the consequence of ACE2 presence in
the skin. The possible mechanisms of COVID-19 clinical manifestations in the skin
are upregulated innate immune human response, hypercoagulable state, and non-
structural proteins in SARS-CoV-2. These processes are presented as different
dermatologic manifestations, which are maculopapular rash, papulovesicular rash,
and livedo reticularis. This review aims to link the theoretical framework and
published findings to establish the connection between ACE2 expression in skin and
cutaneous manifestations of COVID-19.
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