Background: Data on the clinical patterns and histopathology of SARS-CoV-2 related skin lesions, as well as on their relationship with the severity of COVID-19 are limited. Methods and Materials: Retrospective analysis of a prospectively collected cohort of patients with SARS-CoV-2 infection in a teaching hospital in Barcelona, Spain, from 1 April to 1 May 2020. Clinical, microbiological and therapeutic characteristics, clinicopathological patterns of skin lesions, and direct immunofluorescence and immunohistochemical findings in skin biopsies were analyzed. Results: Fifty-eight out of the 2761 patients (2.1%) either consulting to the emergency room or admitted to the hospital for COVID-19 suspicion during the study period presented COVID-19 related skin lesions. Cutaneous lesions could be categorized into six patterns represented by the acronym “GROUCH”: Generalized maculo-papular (20.7%), Grover’s disease and other papulo-vesicular eruptions (13.8%), livedo Reticularis (6.9%), Other eruptions (22.4%), Urticarial (6.9%), and CHilblain-like (29.3%). Skin biopsies were performed in 72.4%, including direct immunofluorescence in 71.4% and immunohistochemistry in 28.6%. Patients with chilblain-like lesions exhibited a characteristic histology and were significantly younger and presented lower rates of systemic symptoms, radiological lung infiltrates and analytical abnormalities, and hospital and ICU admission compared to the rest of patients. Conclusion: Cutaneous lesions in patients with COVID-19 appear to be relatively rare and varied. Patients with chilblain-like lesions have a characteristic clinicopathological pattern and a less severe presentation of COVID-19.

Congenital erythropoietic porphyria (CEP) or Günther's disease is a rare autosomal recessive disease resulting from deficient uroporphyrinogen III synthase (UROS) activity mostly due to homozygous mutations in the UROS gene and less frequently in GATA1. 1 CEP commonly presents at birth with cutaneous photosensitivity blistering hypo-and hyperpigmentation severe scarring and deformities. Erythrocyte porphyrin deposition leads to severe hemolysis secondary splenomegaly and pancytopenia which compromises these patients' life expectancy. 1 An exceedingly rare variant of CEP with late-onset (acquired erythropoietic uroporphyria [AEU]) has been described which can be clinically indistinguishable from porphyria cutanea tarda (PCT). Most patients with AEU have a history of myeloid malignancy present with a mild phenotypic expression and with the characteristic urine and blood porphyrin profile of CEP (elevated type I porphyrin isomers) but with normal enzymatic UROS erythrocytic activity and no UROS GATA1 or ALAS2 germline mutations. 2 These cases must be distinguished from patients with germline (homozygous mutants or compound heterozygotes) UROS mutations and mild phenotypic expression (late-onset milder forms of true CEP). 3 Here we report on a patient with AEU associated with myeloid malignancy (AEU-MM) and present a review of the literature.

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Dear Editor, Granuloma annulare (GA) is a granulomatous, idiopathic, inflammatory skin disorder characterized by the formation of papules and plaques with annular and acral distribution. 1 GA is often limited and self-resolving, but in some cases, it can be generalized and refractory toThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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Digital ischemia triggered by coronavirus disease 2019 in a patient under cemiplimab treatment Dear Editor, Cutaneous manifestations of coronavirus disease 2019 (COVID-19), including pseudo-chilblain, vesicular, maculopapular, urticaria, and livedo/necrosis 1 lesions, have been widely reported. Anti-programmed cell death protein-1 (PD-1) immune checkpoint inhibitors have dramatically changed the treatment of locally advanced and metastatic squamous cell carcinoma (SCC). Likewise, Raynaud's phenomenon and acral necrosis related to anti-PD-1 have been described. 2 We present the case of a woman receiving cemiplimab who presented with digital ischemia and positive COVID-19 serological tests. A heavy-smoker, 48-year-old woman with a history of hypertension and an unresectable facial basal cell carcinoma, receiving cemiplimab 350 mg intravenously every 3 weeks in a clinical trial (REGN-1620), because of tumoral progression and side effects from treatment with vismodegib, presented in January 2020 (17 months after initiating cemiplimab) with de novo erythematous papulonodular lesions, pallor, and cyanosis on fingertips. She was diagnosed with idiopathic chilblains and Raynaud's phenomenon, which resolved after cold avoidance strategies. In April 2020, she presented at the Emergency Department with painful digital distal ulcers. She denied having COVID-19-related respiratory symptoms. Physical examination showed white-grayish coloration with a necrotic scar and bullae formation on the second, third, and fourth fingertips of the right hand, and erythema with a punctiform necrotic scar on the fifth fingertip of the left hand (Fig. 1). RT-PCR and serologic tests for COVID-19 were performed, revealing negative PCR, positive IgG, and negative IgM antibodies. Blood tests showed high D-Dimer levels (2,500 ng/ ml, reference value <500) and low titer (1:40) antinuclear antibodies. Systemic sclerosis and antiphospholipid syndrome antibodies were negative. Angiotensin-converting enzyme inhibitors and beta-blockers were stopped, while amlodipine 10 mg b.i.d.