key: cord-0736734-9n5sjn23
authors: Rodríguez‐Jiménez, Pedro; Chicharro, Pablo; De Argila, Diego; Muñoz‐Hernández, Patricia; Llamas‐Velasco, Mar
title: Reply to “Acute urticaria with pyrexia as the first manifestations of a COVID‐19 infection”: Urticaria‐like lesions in COVID‐19 patients are not really urticaria. A case with clinicopathologic correlation
date: 2020-05-09
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16618
sha: b88c4e83b2e79113134de76c3b6b33ed3c58dfef
doc_id: 736734
cord_uid: 9n5sjn23

We have read with great attention the article by Van Damme et al. considering urticarial lesions as a coronavirus disease 2019 (COVID‐19) associated skin manifestation(1). They observed two patients with erythemato‐edematous lesions surrounded by whitish halo, thus similar to hives but without additional data on their evolution(1). A previous report of COVID19‐related urticarial lesions had also been first published by Recalcati(2). However, none of these two published articles detailed if the lesions where evanescent, as it is mandatory for urticaria, nor did a pathological study.

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Funding sources: None to be declared.

Disclosure Statment: Dr. RODRIGUEZ-JIMENEZ has nothing to disclose, Dr. CHICHARRO has nothing to disclose, Dr. DE ARGILA has nothing to disclose, Dr. MUÑOZ-HERNANDEZ has nothing to disclose and Dr. LLAMAS-VELASCO has nothing to disclose,

This article is protected by copyright. All rights reserved Dear Editor, We have read with great attention the article by Van Damme et al. considering urticarial lesions as a coronavirus disease 2019 (COVID-19) associated skin manifestation 1 . They observed two patients with erythemato-edematous lesions surrounded by whitish halo, thus similar to hives but without additional data on their evolution 1 . A previous report of COVID19-related urticarial lesions had also been first published by Recalcati 2 . However, none of these two published articles detailed if the lesions where evanescent, as it is mandatory for urticaria, nor did a pathological study.

Madrid, Spain, has been considered by the World Health Organization as an area of SARS-Cov-2 of community transmission 3 . Since then, we began to observe different skin manifestations in patients with COVID-19 infection. We present the case of a patient with non-evanescent urticarial lesions and its clinicopathologic correlation.

A 60-year-old woman was admitted to the hospital for dry cough and pyrexia in the previous three weeks. In the last 5 days she developed an urticarial eruption (Fig. 1) . The patient had no relevant past medical history and had only suffered one episode of pompholyx three years ago.

When the cutaneous rash appeared, she was not under any medication. She presented a bilateral interstitial pneumonia on X-Ray and blood test revealed a mild lymphopenia (370/mm³) and increased liver enzymes (GOT, GPT, LDH, GGT three times normal). A cutaneous punch biopsy was performed showing slight vacuolar-type interface dermatitis with occasional necrotic keratinocytes. No eosinophils were encountered. These histological alterations were compatible with an erythema multiforme like pattern (Fig.2) .

On follow up, the lesions were persistent on the same locations without evolving to blistering.

Surprisingly, in the work by Marzano et al 4 , reporting varicella-like lesions on COVID-19 patients, the histological image included in their report resembles our case.

This article is protected by copyright. All rights reserved

In conclusion, we want to highlight that histopathological studies are important to characterize COVID-19 related skin lesions. In our experience, these urticaria-like lesions may also appear in late phases and not only as early manifestations of COVID. Thus, this type of skin lesions should be further studied to clarify its relation with COVID-19 and if it may be useful to identify earlier COVID-19 patients.

But we must remember, that even today, when it seems that all of our patients are affected of COVID-19 and all the skin diseases may be related to it, we have to ground on clinicopathological correlation and to maintain the same quality standards that we used to have before SARS-Cov-2 appeared. This will be the key to unravel our enemy in this battle.

Acute urticaria with pyrexia as the first manifestations of a COVID-19 infection

Cutaneous manifestations in COVID-19: a first perspective

World Health Organization. Novel coronavirus situation reports

Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients