Absence of specific cutaneous
One patient pre-
manifestations of severe acute
respiratory syndrome coronavirus
2 in a reference center in Brazil
To the Editor: We read with interest the letters from
the New York City report regarding the absence of
COVID toe lesions on their patients and the recom-
mendation of caution when concluding that cuta-
neous findings are specifically due to severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2).1,2
Since the global pandemic of SARS-CoV-2, the
University of S~ao Paulo Medical School Hospital—a
reference center and one of the largest university
hospitals in Latin America—reorganized its structure,
offering about 300 intensive care units and 500
nursery beds fully dedicated to SARS-CoV-2. Five
staff members of the Dermatology Department were
exclusively assigned to assist the admitted patients
who presented with dermatologic lesions. As of May
2020, Brazil, especially the city of S~ao Paulo, became
one of the new epicenters of the pandemic. By July
31, the state of S~ao Paulo had a total of 542,304
confirmed cases and 22,997 deaths.
From March 31 to July 31, 2020, 3982 patients
were hospitalized with severe pulmonary manifes-
tations of the disease, either in intensive care units or
nursery beds. The dermatology team was called to
visit a total of 98 patients, and the diagnosis of SARS-
CoV-2 was confirmed either by polymerase chain
reaction or serology in 86 of them. Patients were
always evaluated in person by at least 2 experienced
dermatologists at every visit.
To our surprise, despite the reports of diverse
cutaneous manifestations related to SARS-CoV-2,
among the 86 patients with confirmed COVID-19, it
was not possible to attribute with certainty that any
cutaneous lesions had a direct correlation to the
SARS-CoV-2 infection.3,4 The profile of dermatosis
observed was similar to what was usually seen
before the pandemic, with fungal infections being
the most frequent cause, followed by drug eruptions
and viral infections.
Six patients with confirmed SARS-CoV-2 pre-
sented an exanthema that rapidly resolved and could
arguably be related to the viral infection. All of them
had received either antipyretics, anti-inflammatories,
or antibiotics before or during their hospital stay, and
the temporal relationship between the rash devel-
opment and the use of those drugs led us to consider
drug-induced exanthema to be a more likely hy-
pothesis. This differentiation between viral or drug-
induced exanthems is always challenging, even
J AM ACAD DERMATOL
without the pandemic scenario.
sented with acral areas of erythema and a history of
systemic lupus, leading us to the hypothesis of
chilblains, instead of the recently described COVID
toes.
Therefore, because the pandemic is still ongoing,
with new countries assuming the epicenter posi-
tions, and new data are being published by the day,
we agree that every skin lesion should be suspected
to be a virus-related manifestation. However, we
also recommend caution when concluding that
some cutaneous findings are specifically induced
by the virus. Thus, we would like to share our
experience as the largest reference center for this
epidemic in Brazil: with an in-person evaluation of
patients with laboratory and clinical confirmation of
severe systemic COVID-19 manifestations, no spe-
cific SARS-CoV-2 cutaneous findings were reported.
Joao Avancini, MD, Denise Miyamoto, MD, PhD,
Marcelo Arnone, MD, Tatiana Villas Boas Gabbi,
MD, Paula Silva Ferreira, MD, PhD, Cyro Festa-
Neto, MD, PhD, and Jose Antonio Sanches, MD,
PhD
From the Department of Dermatology, University of
S~
ao Paulo, S~
ao Paulo, Brazil.
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the authors.
Correspondence to: Joao Avancini, MD, Av Dr Eneas
de Carvalho Aguiar 255, Room 3068, S~ ao Paulo,
SP Brazil
E-mail: joao.avancini@hc.fm.usp.br
REFERENCES
1. Deutsch A, Blasiak R, Keyes A, et al. COVID toes: phenomenon
or epiphenomenon? J Am Acad Dermatol. 2020;83:e347-e348.
2. Vesely MD, Perkins SH. Caution in the time of rashes and
COVID-19. J Am Acad Dermatol. 2020;83:e321-e322.
3. Marzano AV, Cassano N, Genovese G, Moltrasio C, Vena GA.
Cutaneous manifestations in patients with COVID-19: a pre-
liminary review of an emerging issue. Br J Dermatol. 2020;183:
431-442.
4. Galvan Casas C, Catala A, Carretero Hernandez G, et al.
Classification of the cutaneous manifestations of COVID-19: a
rapid prospective nationwide consensus study in Spain with
375 cases. Br J Dermatol. 2020;183(1):71-77.
https://doi.org/10.1016/j.jaad.2020.09.030
JANUARY 2021 e67