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

Abstract

BackgroundDescriptions of cutaneous findings associated with COVID‐19 have not been consistently accompanied by histopathology or confirmatory testing for SARS‐CoV‐2.ObjectiveTo describe and classify the cutaneous findings with supporting histopathology of confirmed COVID‐19 inpatients.MethodsWe 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.ResultsTwenty‐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.LimitationsThere is no gold‐standard test to distinguish between viral exanthems and drug reactions.ConclusionA histopathological study is critical before attributing skin findings to a manifestation of COVID‐19.