Not all that glitters is COVID-19: a case-series demonstrating the need for histopathology when skin findings accompany SARS-CoV-2 infection

A Barrera-Godínez, S Méndez-Flores, M Gatica-Torres, A Rosales-Sotomayor, K I Campos-Jiménez, D M Carrillo-Córdova, M C Durand-Muñoz, G L Mena-Hernández, Y K Melchor-Mendoza, A L Ruelas-Villavicencio, A García-Irigoyen, G A Acatitla-Acevedo, S Toussaint-Caire, J Domínguez-Cherit
Journal of the European Academy of Dermatology and Venereology: JEADV 2021 May 20

BACKGROUND: Descriptions of cutaneous findings associated with COVID-19 have not been consistently accompanied by histopathology or confirmatory testing for SARS-CoV-2.

OBJECTIVE: To describe and classify the cutaneous findings with supporting histopathology of confirmed COVID-19 inpatients.

METHODS: We included consecutive inpatients with a confirmed diagnosis of COVID-19 for whom a dermatology consult was requested. A skin biopsy was performed in all cases. Skin findings were classified as being compatible with a cutaneous manifestation of COVID-19 or as representing a distinct clinical entity.

RESULTS: Twenty-eight patients were studied in whom thirty-one dermatologic diagnoses were made. Twenty-two of the dermatoses were compatible with a cutaneous manifestation of COVID-19; nine entities were not associated with infection by SARS-CoV-2. The most common COVID-19-associated pattern was an exanthematous presentation. In four patients, a new pattern was observed, characterized by discrete papules with varied histopathological findings including a case of neutrophilic eccrine hidradenitis. No cases of pernio-like lesions were identified. Skin findings not associated with COVID-19 represented 29% of diagnoses and included Malassezia folliculitis, tinea, miliaria, and contact dermatitis.

LIMITATIONS: There is no gold-standard test to distinguish between viral exanthems and drug reactions.

CONCLUSION: A histopathological study is critical before attributing skin findings to a manifestation of COVID-19.

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