SDRIFE-like rash associated with COVID-19, clinicopathological correlation.

Dear Editor,

Symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE)‐like rash has been recently reported as a skin manifestation potentially associated with coronavirus disease 2019 (COVID‐19).

A 73‐year‐old woman positive for SARS‐CoV‐2 by nasopharyngeal swab PCR test was admitted to the intensive care unit (ICU) with severe hypoxaemia and a bilateral pneumonia on X‐ray. She was hospitalised ten days before, starting treatment with hydroxychloroquine and azithromycin. On the second day of hospitalisation, she developed an erythematous rash on both axillae and antecubital fossae, which extended on the following days to the trunk and the inner thighs, leaving the face unaffected (Fig. 1). No clinical pustules were found. The patient had a fever from the beginning of the illness. Histopathological analysis of a punch biopsy showed subcorneal pustules and superficial infiltrates of lymphocytes and eosinophils (Fig. 2). Blood test showed lymphopaenia without neutrophilia. Both hydroxychloroquine and azithromycin were interrupted at her admission to the ICU and intensive treatment with systemic steroids, and broad‐spectrum antibiotic was initiated. She did not take antiviral therapy throughout her hospitalisation. The rash progressively disappeared over the following seven days.

Figure 1

Erythematous rash extending from the left axilla to the trunk.

Figure 2

Subcorneal pustule and superficial infiltrates of lymphocytes and eosinophils (HE, x20).

Our case clinically resembles a SDRIFE‐like rash in a COVID‐19 scenario; however, the presence of subcorneal pustules is the main histopathological hallmark in acute generalised exanthematous pustulosis (AGEP), rather than a common finding in typical SDRIFE. Both diseases are typically related to drug intake, although they have occasionally been associated with viral infections. , In our case, there was a high suspicion of a possible drug reaction. Therefore, it remains uncertain whether the proinflammatory features associated with SARS‐CoV‐2 infection could have further enhanced neutrophilic recruitment and activation thereby predisposing our patient to develop a more intense pustular drug reaction or whether the lesion was an atypical SDRIFE‐like rash secondary to COVID‐19.