A case for palliative dermatology: COVID-19–related dermatoses

Abstract

The unprecedented coronavirus disease 2019 (COVID-19) pandemic has challenged health care systems in different ways. In the United Kingdom, various subspecialties are deployed to the wards to help medical workforce in the frontlines, with dermatologists helping with general medical wards and on-calls. We present a case of COVID-19–related urticaria manifesting in a palliative setting and responding well to systemic antihistamine. This pandemic has highlighted a new subspecialty that should be explored and researched—palliative dermatology—bridging elements of dermatology with the concepts of palliative medicine. As dermatologists, we should be in the position to help with the last stages of a patient’s journey.

Introduction

The unprecedented coronavirus disease 2019 (COVID-19) pandemic has challenged health care systems in different ways. In the United Kingdom, various subspecialties are deployed to the wards to help medical workforce in the frontlines, with dermatologists helping with general medical wards and on-calls.

We present the case of a 79-year-old woman who presented to the acute medical ward with a recent fall, cough, fever, and shortness of breath. She had a background of chronic heart failure, atrial fibrillation, hypertension, and vascular dementia. Viral swab confirmed the presence of COVID-19. Unfortunately, signs of respiratory failure developed and progressed, and due to her frailty and medical comorbidities, noninvasive ventilation and intubation were not deemed appropriate.

After discussion with our local palliative care team, it was agreed that symptomatic management should be the priority of care, managing the distressful breathlessness with a continuous subcutaneous infusion of morphine.

The medical ward team was asked by the nursing team to review her newly developed dermatitis, as they were tending her bedside care. In this particular instance, the medical ward was attended by a recently deployed dermatology trainee. Clinical examination suggested new, erythematous urticated plaques limited to her thighs (Figure 1 ) in keeping with urticaria, likely secondary to COVID-19 given the lack of other potential triggers.

Fig. 1.

Erythematous urticated plaques limited to the thighs presenting in a COVID-positive patient with terminal breathlessness.

We were able to manage her clinical manifestations of itch with menthol in aqueous cream and her urticaria with subcutaneous chlorphenamine due to her inability to tolerate oral tablets. Unfortunately, our patient died within a few days of admission, succumbing to the viral infection.

A novel member of the human coronavirus, recently identified in Wuhan, China,¹ officially named as “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2), can cause COVID-19. COVID-19 has been reported to be associated with many systemic clinical manifestations, including dermatologic manifestations with urticarial eruptions commonly reported in various contributions.[2], [3], [4], [5], [6] As in our case, COVID-19–related urticaria can manifest in a palliative setting and responds well to systemic antihistamine.

As dermatology services are returning to a new normal, this pandemic has highlighted a new subspecialty that should be explored—palliative dermatology—bridging elements of dermatology with the concepts of palliative medicine.⁷ Dermatologic conditions may often be overlooked in a palliative care setting, and sometimes rightfully so, especially in the last moments of a patient’s journey; however, we as dermatologists can further help our medical and nursing colleagues by providing diagnostic and management advice in helping patients in their terminal hospital or hospice admission, which has traditionally been guided solely by the palliative care teams.

Disclosure

As the patient depicted in this contribution has sadly died, the next of kin has given written informed consent to publication of her case details.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.