ACE2 receptor in the skin and cutaneous manifestations of SARS-CoV-2: a review of the literature

Denita, Meiliani

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.