A. Pressure necrosis
Results of the biopsy specimen of the left ear revealed epidermal and dermal necrosis and ulceration; there was also necrosis of the eccrine glands (Figure, D). Although eccrine necrosis is not a specific finding, it is a consistent finding in pressure necrosis. The necrotic plaques improved and then resolved after prone positioning was discontinued and further pressure on the ears was avoided.
Pressure necrosis occurs from a lack of blood flow secondary to mechanical stress on the skin. Pressure necrosis in patients who are bedridden involves the sacral region. However, patients who are persistently hypoxemic often require prone positioning, subjecting other anatomic sites to prolonged pressures that exceed local capillary pressure.1 Prone positioning, often greater than 16 hours a day, is used as a therapy for moderate-to-severe cases of COVID-19 that require intubation. A retrospective cohort study highlighted the high incidence of facial pressure injuries in patients with severe COVID-19 who require prone positioning (47.6%), with a substantial association of duration of proning with ulcer development.2