Comment on: Cutaneous manifestations in COVID-19: a first perspective. Safety concerns of clinical images and skin biopsies.

Dear Editor

We have read with great interest the article: Cutaneous manifestations in COVID‐19: a first perspective by Recalcati S. This article is the first report of the cutaneous manifestations in Coronavirus Disease 2019 (COVID‐19) patients during the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic in Lombardy, Italy. From a total of 88 included patients that were evaluated by dermatologists, 18 developed skin involvement, namely erythematous rash (n = 14), widespread urticaria (n = 3) and chickenpox‐like vesicles (n = 1). However, no clinical images are available in the article because of the risk involved in infecting other people.

We would like to report our current experience in the Ramon y Cajal Hospital, Madrid, Spain. As it occurred in Italy, dermatologists are currently involved in the first line due to staff shortages. Because of the elevated number of COVID‐19 inpatients in our hospital, a ‘MACRO‐COVID’ unit was created on March 18, three days after a state of emergency was declared. Every medical and surgical specialty was integrated in this unit to provide assistance in the medical wards, overcrowded with COVID‐19 patients.

To evaluate skin alterations in COVID‐19 inpatients, we are currently performing a simple and easily reproducible method. Dermatologists and non‐dermatologists who are in charge of patients with COVID‐19 and skin signs, are using zip lock transparent bags to transport their mobile phones or other photographic devices (Fig. 1). These disposable bags are made of low‐density polyethylene, allowing high‐quality pictures trough their transparent material and permitting glove interaction with current smartphones. After the evaluation, these sealed bags are dipped in a container with a 70% ethanol solution, thus being completely disinfected. This is a safe method to avoid unnecessary visits, attempting to reduce person‐to person spread.

Figure 1

Zip lock transparent bags are used to transport photographic devices and biopsy dispensable tools. From left to right: liquid petrolatum jelly, povidone‐iodine solution, silver nitrate sticks, surgical blade and 25G subcutaneous needle, local anaesthetic, syringe, 5‐mm punch and formaldehyde container.

We are also performing biopsies in these patients when indicated. The same plastic bags are used to introduce disposable instruments (Fig. 1), in order to avoid sterilization. After local anaesthesia, we use a 4 or 5‐mm biopsy punch to cut the skin. The skin sample is lifted with a 25G subcutaneous needle and then cut with the scalpel blade. A silver nitrate stick is used for haemostasis (optional) and the skin is covered with liquid petroleum jelly. The biopsy recipient is also sterilized in a 70% ethanol solution.

We present an example of an urticariform rash in a 32‐years‐old woman with COVID‐19 (Fig. 2). It appeared 6 days after the onset of symptoms. Hydroxychloroquine and azithromycin had been administered for 4 days. Histologic examination revealed a perivascular infiltrate of lymphocytes, some eosinophils and upper dermal oedema. Oral antihistamines were added to her treatment, with clinical and symptomatic improvement in a 5‐days period.

Figure 2

Picture of an urticariform rash in a 32‐years‐old woman inpatient with COVID‐19. Evanescent hives were present for 5 days, predominantly on the lower trunk and thighs.

We are currently performing a prospective study to describe the clinical and histological characteristics of cutaneous manifestations in COVID‐19. In our preliminary experience, we have also found some cases of unspecific maculopapular rash (some of them with a purpuric component) and urticaria. As stated by Recalcati S, it appears that the SARS‐CoV‐2 may produce similar skin alterations to other common viruses.

First clinical descriptions of COVID‐19 in China are scarce regarding skin involvement. From a 1099 cohort of confirmed COVID‐19 patients, only 2 presented ‘skin rash’ without any further description. Dermatologists have a unique opportunity to make our contribution during this pandemic and adequately describe skin manifestations of COVID‐19. Time is of the essence. Our method is easily replicable, preventing possible transmissions, and providing a correct dermatological evaluation.

Acknowledgement

The patients in this manuscript have given written informed consent to the publication of their case details.