Not all that glitters is COVID-19: a case series demonstrating the need for histopathology when skin findings accompany SARS-CoV-2 infection

Abstract

Background: Descriptions of cutaneous findings associated with COVID-19 have not been consistently accompanied by histopathology or confirmatory testing for SARS-CoV-2. Objective: To describe and classify the cutaneous findings with supporting histopathology of confirmed COVID-19 inpatients. Methods: We included consecutive inpatients with a confirmed diagnosis of COVID-19 for whom a dermatology consult was requested. A skin biopsy was performed in all cases. Skin findings were classified as being compatible with a cutaneous manifestation of COVID-19 or as representing a distinct clinical entity. Results: Twenty-eight patients were studied in whom thirty-one dermatologic diagnoses were made. Twenty-two of the dermatoses were compatible with a cutaneous manifestation of COVID-19; nine entities were not associated with infection by SARS-CoV-2. The most common COVID-19-associated pattern was an exanthematous presentation. In four patients, a new pattern was observed, characterized by discrete papules with varied histopathological findings including a case of neutrophilic eccrine hidradenitis. No cases of pernio-like lesions were identified. Skin findings not associated with COVID-19 represented 29% of diagnoses and included Malassezia folliculitis, tinea, miliaria and contact dermatitis. Limitations: There is no gold-standard test to distinguish between viral exanthems and drug reactions. Conclusion: A histopathological study is critical before attributing skin findings to a manifestation of COVID-19.