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A man in his 40s with a medical history of factor VII deficiency hemophilia presented with acute hypoxic respiratory failure secondary to COVID-19. Following admission, he was intubated with prone positioning, and treatment with tocilizumab and dexamethasone was started. He was also found to have Staphylococcus hemolyticus bacteremia, and treatment with cefepime was initiated. Three days after admission, the patient developed erythema and edematous necrotic plaques of the bilateral ears (Figure, A and B). No devices had been used on the ears. The necrosis progressed during the following days, primarily involving the earlobe of the right ear and a large portion of the helix of the left ear. A punch biopsy specimen was performed (Figure, C and D).
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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
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Kiran Motaparthi, MD, Department of Dermatology, University of Florida College of Medicine, 4037 NW 86 Terrace, 4th Floor, Gainesville, FL 32606 (firstname.lastname@example.org).
Published Online: April 13, 2022. doi:10.1001/jamadermatol.2022.0745
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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