Acute Skin Failure Associated with Severe COVID-19

The term “skin failure” refers to skin changes seen toward the end of life or during a period of acute critical illness.¹ Resulting ulcerations are suspected to occur secondary to multisystem organ failure, hypoperfusion, and “skin death” (a distinguishing characteristic from pressure ulcers). Often appearing as a characteristic butterfly-shaped or pear-shaped lesion, these areas may have rapid progression from skin discoloration to overt tissue necrosis.² Literature on an association of severe COVID-19 with iatrogenic pressure injuries is accumulating,³ but acute skin failure has been overlooked as a source of cutaneous morbidity in critically ill patients with COVID-19.

We recently treated a 55-year-old man with COVID-19 who initially presented with acute respiratory distress syndrome. His initial treatment included mechanical ventilation and administration of tocilizumab, remdesivir, and convalescent plasma. He was transferred to our institution for escalation of care and management of multisystem organ failure involving increasing vasopressor requirement, initiation of continuous venovenous hemofiltration, and treatment of sepsis/bacteremia and thrombocytopenia.

Despite an every-2-hour repositioning protocol (no prone positioning was instituted), on illness day 28, the rapid appearance of a large, butterfly-shaped area of skin discoloration and desquamation over the sacrococcygeal and gluteal region was noted (Fig. 1), clinically consistent with acute skin failure. Given the patient’s critical illness, this was initially managed with local wound care measures. With intensive care and supportive measures, the patient recovered from COVID-19 and multisystem organ failure.

Fig. 1.

Acute skin failure in a critically ill patient with severe COVID-19 was identified with rapid appearance of a butterfly-shaped ulceration in the gluteal area despite frequent repositioning.

Serial surgical débridement and negative pressure wound therapy began on illness day 70, which revealed soft tissue necrosis resulting in a composite wound measuring approximately 18 × 18 cm. After a period of acute rehabilitation, the patient underwent soft-tissue reconstruction on illness day 104 using bilateral V-Y fasciocutaneous flaps. Three weeks later, a progressive sitting protocol was instituted in an inpatient rehabilitation unit. The patient was ultimately discharged on illness day 153 and his wound was well healed on outpatient follow-up (Fig. 2).

Fig. 2.

After serial débridement, wound care, and reconstruction with bilateral V-Y fasciocutaneous flaps, the wound was healed at follow-up.

The COVID-19 pandemic has taken an immense toll on our health care system. Skin-associated complications of COVID-19 include iatrogenic pressure–associated injuries secondary to prolonged intubation or prone positioning.² In contrast, skin failure serves as an umbrella term for failure of this organ, including manifestations at the end of life (ie, Kennedy terminal ulcer) and in critically ill patients (acute skin failure), and must be distinguished from pressure injuries. This differentiation is often challenging for providers.⁴

Our patient developed an ulceration despite frequent repositioning while critically ill with severe COVID-19, consistent with acute skin failure. Although risk factors have been identified, there remains broad underdiagnosis of skin failure as an entity.^1,4 In cases of severe COVID-19 requiring intensive care, providers should be vigilant in early identification of soft tissue necrosis, which may act as a heralding sign. Proper diagnosis has significant implications for prognosis and management, and even litigation.⁴ In an era when frequent resource shortages are present, skin-related complications of COVID-19 may lead to prolonged hospital stays, increased health care costs, and an additional toll on an already strained health care system.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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