COVID-19 bullae/wounds

On March 11, 2020, the World Health Organization declared that COVID-19 met the definition of a pandemic. On that day, there were 3 COVID-19 patients hospitalized within our medical center, the Montefiore Health System in New York. By April 13, the COVID-19 surge had peaked in New York City, which had become the epicenter of the pandemic, with 1,912 COVID-positive patients hospitalized on that day in our system (1).

Throughout this surge, and during the gradual downslope that ensued, the Montefiore Wound Healing Program continued its inpatient consultation service at four hospitals (3 adult and 1 pediatric) across Montefiore’s Bronx campuses.

With our hospitals converted to predominantly COVID-19 units, the wound team was consulted on a number of uncommon wounds that appeared uniquely related to COVID-19. COVID-related skin changes (2), (3) ranging from urticaria to livedo reticularis and acral ischemia (4) that came to be labeled as “COVID toes,” have been previously described (5), (6), (7), (8), (9).

This paper adds to the literature on potentially COVID-related skin changes by describing a series of three cases of lower extremity bullae (two hemorrhagic and one non-hemorrhagic) in patients hospitalized with COVID-19. Wounds on these patients hospitalized with COVID-19 were bullae that formed in the ankle and plantar surface. Two of the bullae were extensive, in the range of 15cm x 20cm. Serious comorbidities were present in all three patients.

All three patients provided a signed consent for the publication of these photographs

There is no consensus on how to treat these extensive bullae. We describe three patients with 3 different treatment approaches and follow-up results.

This is an early report and needs further exploration with follow-up to healing (for surviving patients) and pathology, as well as contextualization within evolving understanding of the pathophysiology of COVID-19. We think similar cases will be apparent soon in hospitals across the country where wound care providers will be called for recommendation. It would also be helpful to determine factors that lead to their formation.