COVID-19 elbows: first report in Saudi Arabia.

Dear Editor,

Since the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection originated in Wuhan, China, in 2019, it has spread to many countries globally, causing a pandemic. SARS‐CoV‐2 is known to cause a wide spectrum of illnesses, ranging from a mild sore throat and symptoms of a common cold to multiorgan system failure and ultimately death, albeit in a small percentage of cases.

The first case of SARS‐CoV‐2 in Saudi Arabia was reported on March 2, 2020. Subsequently, over a span of 4 months, 2,226,290 polymerase chain reaction (PCR) tests for SARS‐CoV‐2 were conducted for citizens and foreigners residing in Saudi Arabia, and 229,480 cases were found to be positive. The recovery rate was 72% as of July 11, 2020, and the death toll was 2181 individuals (0.95%). The Ministry of Health has instituted strict protocols to contain the spread of the infection in the country. At our center, asymptomatic positive patients and mildly symptomatic patients were enrolled in home quarantine programs. Daily checks were performed by an infection control team.

Soon after the SARS‐CoV‐2 crisis ensued, many hospitals in the country established telemedicine systems, including teledermatology.

A 39‐year‐old otherwise healthy female radiologist tested positive for SARS‐CoV‐2 via polymerase chain reaction 6 days after coming in direct contact with her SARS‐CoV‐2‐positive husband. Her husband contracted the infection at his workplace. She presented with fever, sore throat, headaches, and body aches. After spending two days in home quarantine after being tested, she suddenly developed an intensely pruritic rash over both elbows (Fig. 1). She had no history of local pressure exerted on the affected sites, and she denied using any topical agents that could have caused contact dermatitis before the onset of the rash. She had no history of similar rashes previously and no personal or family history of psoriasis. She was not on any medications, except paracetamol for fever and body aches. A past history of paracetamol allergy was absent. After 4 days of topical application of mometasone furoate 0.1% ointment, the rash improved. A few days later, she developed a similar rash on her knees. However, the rash was faint and mild and resolved without residual skin changes. The differential diagnosis included urticaria, urticarial vasculitis, psoriasis, or a viral rash related to SARS‐CoV‐2. A biopsy could not be performed because of strict home quarantine rules. The rash had a similar appearance to the lesions reported by Estébanez et al, however, our patient’s lesions were pink without any yellowish papules. Our patient had rashes on her elbow and not the heel. Urticaria‐like rashes of the elbow have been published in the photographic atlas of the prospective nationwide consensus study in Spain on the classification of the cutaneous manifestations of SARS‐CoV‐2. Urticaria usually resolves spontaneously within 24 hours of onset. The lesions in our patient remained for about four days, hence, a viral rash was suspected. The absence of residual skin changes excluded urticarial vasculitis. As the rash did not recur after discontinuing the topical steroid, a diagnosis of psoriasis was excluded. A skin biopsy could have aided our diagnosis. On three weeks follow‐up, the rash did not recur. We believe that this report could be a helpful addition to the ongoing studies on the cutaneous manifestations of SARS‐CoV‐2.

Figure 1

Erythematous plaques are observed on the right and left elbows