Lichenoid eruptions with interface dermatitis and necrotic subepidermal blister associated with COVID‐19

Dear Editor,

A 28‐year‐old female nurse working at triage ward of a referral hospital for coronavirus 2019 disease (COVID‐19) presented to our clinic with 1‐week history of generalized severely pruritic rash, sparing her face (Figure 1). She had a history of high fever (39°C), severe headache, and dyspnea 3 weeks ago. Regarding her job and her close contact with COVID‐19 patients, she had been clinically diagnosed as COVID‐19 and treated with paracetamol and azithromycin 250 mg per day. She had received same medications previously without any complication or cutaneous reaction. Her symptoms revealed on day 4, but she developed cutaneous lesions after a week. On physical examination, she had generalized red‐purple papules and plaques. A biopsy from one of her leg lesions revealed vacuolar interface dermatitis with confluent extensive epidermal cell necrosis producing necrotic subepidermal blister associated with superficial perivascular inflammatory dermal reaction containing scattered eosinophils (Figure 2), which could be associated with infections. According to the pathology report and her past history, her cutaneous lesions were assumed a complication of COVID‐19. She was treated with topical steroid and oral loratadin.

FIGURE 1.

Red‐purple papules and plaques (lichenoid eruptions) on lower extremities

FIGURE 2.

Vacuolar interface dermatitis with confluent extensive epidermal cell necrosis producing necrotic subepidermal blister associated with superficial perivascular inflammatory dermal reaction containing scattered eosinophils. A, H&E ×10; B, H&E ×40. H&E, hematoxylin and eosin

Since December 31, 2019, SARS‐CoV‐2 was introduced to the world, different cutaneous manifestations have been described. ¹ , ² , ³ , ⁴ However, to our knowledge, lichenoid eruption has not been reported in a COVID‐19 patient yet. Furthermore, most of the previous reports lack clinical images of the patients and especially pathologic evaluation of the cutaneous lesions. Our case, having both these features, could contribute to better understanding of the underlying pathology of the disease, which seems more complicated than the simple clinical presentation.