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Resumen Las metástasis cutáneas de melanoma en el área de donde se extrae la piel para cubrir el defecto de la extirpación de la lesión inicial son raras, existiendo pocas publicaciones al respecto. Presentamos el caso inusual de un paciente de 60 años de edad con diagnóstico de melanoma en región supraescapular izquierda, al que se realizó cirugía de ampliación de márgenes y reconstrucción con injerto de piel parcial, apareciendo posteriormente múltiples lesiones metastásicas de aspecto papular, gris-azuladas, en las zonas receptora y donante del injerto. El hallazgo coincidió con la detección de metástasis hepáticas, pulmonares, retroperitoneales y cerebrales, sugestivas de enfermedad diseminada.

Background: Cutaneous metastasis (CM), while uncommon, is usually an indicator of poor prognosis. With cancer patients living longer, the incidence of CM has increased, which justifies its analysis. Objectives: The objective of this study was to carry out a descriptive study of CM diagnosed for 18 years in a dermatology department of a tertiary care hospital and to assess the epidemiological, clinical, and histological variables that condition them, as well as data on their survival and prognosis. Methods: We performed a descriptive study of cases of CM diagnosed over 18 years in the dermatology department of a tertiary referral hospital analyzing the following variables: patient age and sex, site of primary neoplasm, pathochronology, survival time, histological findings, immunohistochemical markers, the anatomical area affected, the clinical appearance of the metastasis, therapeutic plan, and existence of metastases in other regions. We checked normal distribution using the Kolmogorov-Smirnov test and then compared the quantitative variables using the Student's t-test (unpaired samples), Mann-Whitney test (non-normal distribution), analysis of variance (ANOVA; for more than two groups), and categorical variables using the chi-square or Fisher’s exact test. Results: We included 37 cases (20 men and 17 women), of whom 32 had died. The mean age was 62 ± 15 years. CM detection was defined early in 8% of cases, synchronous in 32%, and metachronous in 60%. The most frequent primary tumor sites were lungs (24%), breasts (21%), and bladders (11%). Most metastases were solitary. The most frequent locations for CM were the scalp, trunk, armpits, and groin. Most lesions had a nodular presentation (81%). Squamous cell carcinoma and adenocarcinoma showed the same frequency in lung cancer CM. Breast cancer leading to CM was the most common invasive ductal carcinoma. The most aggressive cases, with the worst survival, originated in lung neoplasms. Therapeutic management for most patients involved surgery in combination with other procedures. The only difference detected between the lung and breast cancer CM was the predominance of lung tumors in men (89%) and breast tumors in women compared with metastases from other sites; breast cancer CM manifested more frequently as plaques and less frequently as nodules (p < 0.05) and was less frequently associated with multisystemic metastasis. In lung cancer CM, time from tumor diagnosis to CM occurrence was shorter (p < 0.01) and multisystemic metastasis was more frequent than in CM of other tumors. Conclusions: CM tends to affect patients aged above 60 years and arises predominantly from lung cancer in men and breast cancer in women. The most typical locations are the chest and scalp, and the appearance is usually nodular. Survival after CM detection is low, particularly in lung cancer CM.

A 4-year-old girl presented with a 2-month history of round, hypopigmented, slightly scaly patches measuring 1-6 cm and encircled by an erythematous halo, first appearing on the lower limbs then spreading to the whole body. Three biopsies were taken as the condition progressed, each showing a lymphocytic infiltrate affecting a medium-sized artery at the dermal-subcutaneous junction, with a concentric fibrin ring. These findings are characteristic of lymphocytic thrombophilic arteritis (LTA). The young age of our patient and the type of skin lesions she developed make this an atypical presentation of LTA, which usually manifests as hyperpigmented macules on the lower extremities, predominantly in dark-skinned women.

Chilblain‐like acral lesions have been identified in some coronavirus disease 2019 (COVID‐19) patients. It has been suggested that these pseudo‐chilblains could be a specific marker of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. Most patients with these lesions have had negative polymerase chain reactions (PCRs), but some authors believe serology tests are likely to give positive results. We designed a prospective study including all patients with pseudo‐chilblains treated in outpatient department in April and May 2020 and then performed SARS‐CoV‐2 PCR and serology tests on all available patients. We evaluated 59 patients, of whom 17 had undergone PCR before the study period, all with negative results. For the present study, we performed 20 additional PCRs, serology tests in 25 patients, and a parvovirus B19 antibody test in 15 patients. All results were negative. Our findings counter the hypothesis that serology is likely to reveal SARS‐CoV‐2 infection in patients with pseudo‐chilblains. One hypothesis for our negative results is that the time period between symptom onset and antibody production is longer in these patients; another is that the lesions are caused by behavioral changes during lockdown rather than SARS‐CoV‐2 infection. We nevertheless maintain that COVID‐19 should be ruled out in people presenting with chilblain‐like lesions.

Recently, young COVID‐19 patients have presented with erythematous and purpuric acral lesions similar to chilblains1–3. Despite the scarcity of published cases, this topic has attracted significant mass media attention.4 Dermatologists have noted that more people than would be expected at this time of year are seeking medical attention for these chilblain‐like lesions. Some have suggested that people presenting with this manifestation should be tested and isolated2. Determining the accuracy of this association is therefore crucial. To establish the real prevalence of COVID‐19 in patients with acral skin lesions, we firstly evaluated all the cases of acral lesions presented in dermatology and paediatrics departments and family doctors’ offices in an eastern Spanish region over a three‐week period. Then we prospectively performed a SARS‐CoV‐2 PCR on nasopharyngeal aspirates taken from all available patients to determine whether their cutaneous manifestations were predictive of a positive result. To put our findings into context, we reviewed all the articles published before May 2020 concerning COVID‐19 patients with cutaneous lesions. We evaluated 58 patients, whose characteristics are summarized in Table 1. In most cases, lesions were chilblain‐like. Fifteen patients had already been tested, and only one had a positive result: an 85‐year‐old man admitted for severe Covid‐19 pneumonia. He had an ulcer on a toe that was finally determined to be vascular in nature. We performed prospective PCR testing in 24 patients. All test results were negative. In total, then, PCR was negative in 38 patients and positive in a single patient whose lesion was very unlikely to be due to COVID‐19. Our bibliography search returned 97 articles and we found 2 more through cross‐references. Nine of these articles dealt with acral lesions specifically. Their results are summarized in Table 2. Data published in the literature are heterogeneous, as are the methods employed to collect them. The first papers looked at cutaneous manifestations in patients with confirmed SARS‐CoV‐2 infection.5–8 This approach cannot reveal whether this dermatologic manifestation is a specific marker of SARS‐CoV‐2 infection, since patients without COVID‐19 are not included. The other approach, which we have followed, is to analyse all patients with acral lesions. This can be done retrospectively, reporting on patients in the sample who have already been tested, or prospectively, performing the test on all available patients, regardless of whether they have symptoms. The retrospective method has a significant risk of confounding bias: due to the scarcity of COVID‐19 tests8, they are usually reserved for patients with COVID‐19‐related symptoms, who are obviously more likely to test positive. All previous studies including only patients with cutaneous acral lesions (summarized in table 2) have been retrospective, and only a minority of patients were tested. In total, 12 out of at least 49 tested patients were positive (24.5%). Combined with our results, they total 13 positives out of 88 tests (14.8%). There are two possible explanations for the high proportion of negative results: I) A high number of false negatives. II) The lesions are not related to SARS‐CoV‐2 infection. The low prevalence of an infected contact in our sample, after three weeks of strict confinement in Spain, makes the possibility of being infected in our cohort less likely. The diffusion of this entity by the mass media may have caused patients who would not normally consult to do so.9 . Other possible explanations include a concomitant parvovirus B19 outbreak10 or trauma‐induced lesions. Our study suggests that acral skin lesions are not a specific marker of SARS‐CoV‐2 infection. Although larger prospective studies are needed, current evidence indicates that acral skin lesions should not be regarded as a sign of COVID‐19 in otherwise asymptomatic patients.