To the Editor:
COVID-19 is a disease caused by severe acute respiratory syndrome
coronavirus 2 of the genus Betacoronavirus (SARS-CoV-2). It was first
described in Wuhan (China) on December 2019 and has spread to become a
pandemic. Its clinical presentation is mainly characterized by cough,
fever and dyspnea, although many other symptoms have been described
within its presentation pattern. In some cases, it causes an acute
respiratory distress that has lead to the death of thousands of people
around the world. Furthermore, different type of skin lesions have been
described during the infection period of illness due to
SARS-CoV-2.1 The first report of cutaneous
manifestations described different forms of skin lesions such as
erythematous rash, urticaria and chicken-pox-like
vesicles.2 In this exceptional situation of global
health emergency, physicians are undertaking research work in order to
achieve notions on the etiopathogenesis of these skin lesions.
Acro-ischaemic lesions have also been notified and attributed to
disseminated intravascular coagulation and to the expression of
secondary microthrombosis due to endotelial damage.3-5However, to date, there is no clear understanding on whether the skin
lesions are secondary to the viral infection nor why there are different
presentations of skin lesions for the same viral infection.
We present 4 patients with COVID-19, confirmed by positive polymerase
chain reaction, who were referred to our service due to the appearance
of skin lesions. Two of them developed skin lesions during
hospitalization whilst presenting respiratory symptoms and the other two
developed skin lesions many days after hospital discharge. Demographic
data, description and histology of skin lesions, blood parameters,
clinical symptoms and drugs administered are shown in table I. The
algorithm of the spanish pharmacovigilance system (ASPS), which
evaluates the possible implication of a drug reaction as a cause of the
skin lesions6 was also applied. The ASPS analizes: i)
the interval between drug administration and the aparition of skin
lesions, ii) the degree of knowledge of the relationship between the
drug and the effect described in literature, iii) the evaluation of drug
withdrawal, iv) the rechallenge effect, and v) alternative causes. Each
item receives and individual subscore, and a total sum ≥ 6 indicates a
probable causality.6
As mentioned above, skin lesions appear to be a sign within patients
suffering from COVID-19. To date, no hypothesis has been proposed to
explain if the lesions (including the different types) are attributable
to the virus, to drug adverse reactions or to any other clinical
condition. In our series, small enough to draw conclusions, we have
found no differences between the multiple types of skin lesions and
analytical or clinical features. Even in lesions with apparent vascular
involvement, which have been associated with alterations in
coagulation,3-5 the values detected do not differ from
those with other types of skin lesions. Regarding drug involvement,
since all the patients were exposed to multiple drugs at the same time,
the ASPS was not able to differentiate the possibility of drug
implication nor the immune mechanisms involved. Thus, further assays
with selective (in vitro or in vivo ) tests for each drug
seem necessary in order to completely rule out drug involvement. In
addition, since many patients worldwide are being infected with
SARS-Cov-2, and many of them present similar medical history and receive
the same treatments, it seems necessary to investigate the existence of
an individual predisposition that facilitates the developement of skin
lesions. In this new scenario that we are facing in these last months,
providing light on these still unresolved questions, can contribute to
prevent or to manage the symptoms in an early way.