Absence of specific cutaneous 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 recommendation of caution when concluding that cutaneous 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 São 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 São Paulo, became one of the new epicenters of the pandemic. By July 31, the state of São 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 manifestations 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 presented 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 development and the use of those drugs led us to consider drug-induced exanthema to be a more likely hypothesis. This differentiation between viral or drug-induced exanthems is always challenging, even without the pandemic scenario. One patient presented 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 positions, 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 specific SARS-CoV-2 cutaneous findings were reported.