Cutaneous findings of COVID-19 in a pandemic hot zone
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, July 1, 2020
In this month’s Clinical Applications column, Dermatology World talked to Joanna Harp, MD, director of the inpatient dermatology consult service at Weill Cornell Medicine and New York Presbyterian, about her experience treating patients in New York during the pandemic and her cutaneous findings while treating COVID-19 patients, which will be published in Translational Research.
Dermatology World: Tell us about your experiences working in a COVID-19 hot zone.
Dr. Harp: I serve as director of the inpatient dermatology consult service at Weill Cornell Medicine and New York Presbyterian, so I have always spent a significant portion of my workday assessing skin findings in hospitalized patients. Since the COVID-19 pandemic struck New York City, I have continued my work leading the consult service assessing skin findings in many COVID-19 patients in the hospital. The vast majority of patients admitted to our hospital have COVID-19, though not all, so I am seeing some COVID-19 negative inpatients with other skin issues. Our outpatient practice is largely closed, but I have been participating in outpatient virtual visits.
Dermatology World: What has it been like being on the front lines in what’s been considered a hot zone?
Dr. Harp: It’s been busy, but I hope what we are seeing and learning from the skin will help us understand in some way how and why this virus is making some people so sick. Of course there is heightened anxiety, but when you continually see all of the other doctors, nurses, respiratory therapists, and support staff coming together and working so hard, it helps bring into focus our singular goal of caring for these patients as best we can by bringing our unique skill sets to the table.
Dermatology World: What other specialty physicians are you collaborating with on a frequent basis?
Dr. Harp: Most of our hospital has been converted to an intensive care unit so I am working daily with intensivists and hospitalists. Given some of these patients develop coagulopathies, which can manifest in the skin with purpura and livedo, I have also been working very closely with our hematologists.
Dermatology World: What are you seeing with regard to the COVID-19-positive patients in the ICU with cutaneous issues? Are these generally patients who had skin issues but then developed COVID-19, or patients who had COVID-19 and developed skin issues — either from the virus or treatments for the virus?
Dr. Harp: In a small number of critically ill patients we have noted an emerging pattern of livedoid eruptions and retiform purpura on the arms, legs, and buttocks. Skin biopsies of these patients have demonstrated pauci-inflammatory thrombogenic vasculopathy (i.e., clotting). Many of these patients have also had clinical evidence of systemic coagulopathy, such as pulmonary emboli and ischemic strokes, suggesting their skin findings are cutaneous manifestations of a systemic hypercoaguable state.
So far, we have published three of these cases and two additional small case series of patients have been submitted to dermatology journals and are currently under review. We also plan to include all of these patients in the COVID-19 Dermatology Registry.
Dermatology World: You are seeing new morphologies with these patients. What are you seeing and how is that helping with our understanding of what is happening systemically?
Dr. Harp: In addition to the cutaneous manifestations noted above, there seem to be various other skin findings in COVID-19 patients though none of them seem to be common. I have heard reports and read literature describing pernio-like changes (small, tender, red-purple spots that rarely can blister on the fingers and toes) especially in younger, healthier patients with mild illness, as well as fairly non-specific rashes like urticaria and diffuse papular eruptions and vesicles. We do not yet know the underlying cause of these skin findings or what they might mean for COVID-19 patients. I suspect the various cutaneous morphologies we are seeing may reflect the myriad of different ways our immune system can react to this virus.
Dermatology World: As a physician on the front lines, what are your thoughts about the future? Where does the specialty go from here?
Dr. Harp: I think we must stay involved to provide the best care we can for our patients. Our understanding of these skin findings is just beginning, and we need dermatologists out there assessing the skin, whether that is in person or virtually, to continue to gain as much knowledge and experience as we can. We don’t know yet (and need to find out) whether these skin manifestations should prompt further work up and/or could have implications for treatment of COVID-19.
Joanna Harp, MD, is director of the inpatient dermatology consult service at Weill Cornell Medicine and New York Presbyterian. Her and her colleagues’ findings will be published in Translational Research (doi: 10.1016/j.trsl.2020.04.007).
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DW.
