Conflict of interest: None.

Funding source: None.

Dear Editor,

Since December 2019, an outbreak of Coronavirus disease 2019 (COVID‐19) that started in Wuhan, China, has been spreading across the world and was assessed as a pandemic from March 11, 2020, by the World Health Organization (WHO). Several manifestations related to COVID‐19 have been reported, but small data about skin manifestations in these patients is available. In Mexico, COVID‐19 alert began on February 27, and to date no associated clinical skin manifestations have been reported in our country. Here is our experience with two patients.

Case 1 {#ijd14958-sec-0002}
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A previously healthy 33‐year‐old male arrived to the Emergency Room (ER) on March 26, 2020, with an 11‐day history of fever, diarrhea, altered mental status with aggressiveness, and a 4‐day maculopapular skin rash affecting the trunk and upper and lower limbs. Three days previous to arrival, typhoid fever was diagnosed, and he was treated with ciprofloxacin and metamizole. No cough or dyspnea was reported.

Due to a current measles epidemic outbreak in Mexico, the patient was considered suspicious and evaluated by the Neurology Department, diagnosing acute infectious meningoencephalitis. Laboratory findings included significant anemia (hemoglobin 12.7 mg/dl), elevated lactic dehydrogenase (4268.7 UI/l), and normal chest x‐ray. However, IgM and IgG for measles were negative. Due to persistent skin rash, biopsy of maculopapular rash was performed to exclude erythema multiforme; histologic slides showed nonspecific mild to moderate dermatitis with isolated areas with interphase dermatitis and isolated apoptotic bodies (Fig. [1](#ijd14958-fig-0001){ref-type="fig"}).

![(a) Macular erythematous confluent nonpruritic rash affecting upper trunk. (b) Histological images show some isolated areas with interphase dermatitis and lymphoepitheliosis (Hematoxylin and eosin, ×100)](IJD-9999-na-g001){#ijd14958-fig-0001}

On the sixth day after admission, the patient showed progressing acute respiratory distress syndrome, and molecular assays of respiratory panel were performed with a negative result. Nasopharyngeal swabs were positive for SARS‐COV‐2, and chest CT showed characteristic ground‐glass opacities in both lungs. The patient had a fulminant course in the ICU and died on the 15th day.

Case 2 {#ijd14958-sec-0003}
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A 36‐year‐old male with the diagnosis of human immunodeficiency virus (HIV), referred from another health institution, arrived to the ER on April 14, 2020, with 7‐day history of asthenia, adynamia, and diarrhea. Skin examination showed a 4‐day heterogeneous dermatosis that started in the lower limbs and was characterized by confluent erythematous macules forming larger plaques followed later with pruritic papules spreading upward to the dorsolumbar region (Fig. [2](#ijd14958-fig-0002){ref-type="fig"}). Two days later, he developed a holocranial headache, nasal congestion, dry cough, and fever up to 39.5 °C.

![(a, b) Macular symmetrical, heterogeneous dermatosis affecting limbs with small pruritic plaques that spread upwards to posterior trunk (c)](IJD-9999-na-g002){#ijd14958-fig-0002}

Laboratory findings included lymphopenia 1.7 × 10^3^ U/l, elevated erythrocyte sedimentation rate (ESR) 11 mm/h, elevated ferritin (400 ng/ml), elevated D‐dimer (846), elevated lactic dehydrogenase (227.4 UI/l), and elevated C‐reactive protein (5.04 mg/dl). Nasopharyngeal swabs were positive for SARS‐COV‐2, but chest x‐ray and CT chest were normal. The patient remained stable with mild symptoms and was discharged for home isolation.

Before the COVID‐19 outbreak, exanthems have not been described for other coronaviruses, and recently some skin manifestations associated with this virus have been described, including transient livedo reticularis,[^1^](#ijd14958-bib-0001){ref-type="ref"} erythematous rash (like our cases), widespread urticaria, chickenpox‐like vesicles,[^2^](#ijd14958-bib-0002){ref-type="ref"} and skin rash with petechiae (dengue‐like),[^3^](#ijd14958-bib-0003){ref-type="ref"} but none of these descriptions included the skin manifestations as a previous presentation of common associated COVID‐19 respiratory symptoms,[^4^](#ijd14958-bib-0004){ref-type="ref"} and none included skin biopsy. Indisputably, we need further information to understand how this virus affects skin and describe all the dermatological manifestations of this emerging disease.

We wish to express our appreciation to Dr. Hiram J. Serrano‐Ortíz for the technical support.
