Cutaneous manifestations in COVID-19: a new contribution.

We have read with great interest Dr Recalcati’s review about skin manifestations in COVID‐19 as it is the first report on this subject. In a recent review on clinical characteristics of coronavirus disease 2019 in China, rash was observed in 0.2% of cases. However, from the trained eyes of a dermatologist, this percentage may be higher.

Spain is now the fourth most infected nation in the world with 78.797 confirmed COVID‐19 cases and 6.528 deaths at the moment. As in Italy, there is a lack of medical doctors and dermatologists are involved in triage stations and in the medical wards, especially in Madrid.

Cutaneous manifestations, such as erythematous rash, localized or widespread urticaria, seem to be the most common manifestations in acute severe cases; however, it can be difficult to distinguish the underlying cause (viral infection vs new medication prescribed). A skin rash with petechiae has also been described as a possible initial presentation of COVID‐19 disease, as well as acute haemorrhagic oedema of infancy associated with coronavirus NL63.

We want to report one case of COVID‐19 infection that presented with skin manifestations.

A 28‐year‐old woman with no previous medical history, initially presented with dry cough, nasal congestion, fatigue, myalgias and arthralgias without fever. She tested positive for coronavirus. As she was feeling well, self‐isolation at home was recommended. Four days later, she presented with diarrhoea, ageusia and anosmia. During the following days, she started feeling better but with persistent dry cough, ageusia and anosmia. She only took paracetamol for the first 4 days and did not take any other drugs. Thirteen days after being tested (10 days after last dose of paracetamol), the patient started noticing pruritic lesions on both heels and sent us some photographs. Confluent erythematous‐yellowish papules were observed in both heels (Fig. 1a‐b), without any lesions on the rest of the skin. She denied wearing tight socks, shoes or any local pressure that could explain the distribution of the lesions. A treatment with local corticosteroids was advised. Despite this treatment, three days later, the lesions persisted and became erythematous plaques that were both hardened and pruritic (Fig. 2a‐b). At this point, urticaria, urticarial vasculitis, idiopathic plantar hidradenitis and neutrophilic dermatosis were considered within the differential diagnosis. However, a biopsy was not performed.

Figure 1

Confluent erythematous‐yellowish papules in right (a) and left heel (b).

Figure Figure 2

Intensely pruritic erythematous hardened plaques in right (a) and left heel (b) three days later despite topical corticosteroids.

Differing from Dr Recalcati´s report, the lesions we describe do not look like morbilliform rash, urticaria or chickenpox‐like vesicles; they respect the trunk and are intensely pruritic. The case we report is a mild COVID‐19 disease case with no history of drug intake for the last 10 days. The observed skin manifestations could be related with the COVID‐19 viral infection or with the immune response. We think it is important to report cutaneous manifestations of this new infection that may help us to pay attention, better diagnose and understand the disease.