Objectives Earlier diagnosis and the best management of virus-related, drug-related or mixed severe potentially life-threatening mucocutaneous reactions of COVID-19 patients are of great concern. These patients, especially hospitalized cases, are usually in a complicated situation (due to multi-organ failures), which makes their management more challenging. In such consultant cases, achieving by the definite beneficial management strategies that therapeutically address all concurrent comorbidities are really hard to reach or even frequently impossible. Methods According to the lack of any relevant systematic review, we thoroughly searched the databases until October/5/2020and finally found 57 articles including 93 patients. It is needed to know clinical presentations of these severe skin eruptions, signs and symptoms of COVID in these patients, time of skin rash appearance, classifying drug-related or virus-related skin lesions, classifying the type of skin rash, patients’ outcome and concurrent both COVID-19 therapy and skin rash treatment. Result Severe and potential life-threatening mucocutaneous dermatologic manifestations of COVID-19 usually may be divided into three major categories: virus-associated, drug-associated, and those with uncertainty about the exact origin. Angioedema, vascular lesions, toxic shock syndrome, erythroderma, DRESS, hemorrhagic bulla, AGEP, EM, SJS and TEN, generalized pustular figurate erythema were the main entities found as severe dermatologic reactions in all categories. Conclusion We can conclude vascular injuries may be the most common cause of severe dermatologic manifestations of COVID-19, which is concordant with many proposed hypercoagulation tendency and systemic inflammatory response syndrome as one of the most important pathomechanism of COVID-19so the skin may show these features in various presentations and degrees.

Background: The challenging management of melasma highlights the inadequacies of conventional therapies and their high risk of recurrence. Integrating microneedling for device‐assisted drug delivery with tranexamic acid (TA), recognized for its melanin synthesis inhibition, presents a novel approach that warrants further investigation to fully assess its potential in enhancing melasma treatment efficacy.Methods: Fifty moderate to severe melasma patients participated in this randomized outcome‐assessor‐blinded controlled trial. Patients were randomly allocated into two main groups. Group A received a modified Kligman formula on one hemi‐face on alternate nights for 2 months (A1) and three sessions of microneedling with 10% topical TA on the other hemi‐face at 1‐month intervals (A2). Group B used the same modified Kligman formula on both sides of the face, with one side additionally receiving three sessions of microneedling with 4% TA (B1) and the opposite side with 10% TA (B2). Primary outcomes were % Modified Melasma Area and Severity Index (mMASI) and % visual analogue scale (VAS) change during 6 month follow‐up. Adverse events including post‐inflammatory hyperpigmentation (PIH) and treatment tolerability were recorded.Results: Compared to baseline, the mean mMASI reduction immediately after the final session was higher in A1, B1, and B2 (56.84%, 50.88%, and 55.87%, respectively) than in A2, which saw only a 13.16% reduction. Efficacy notably declined after the cessation of treatment across all groups.While the efficacy within groups A1, B1, and B2 was comparable, microneedling with 4% or 10% TA combined with the topical modified Kligman formula proved more potent in patients at a lower risk of PIH. Overall, 22% of patients reported PIH, particularly in the A2 group (28% of hemi‐faces), with its occurrence significantly associated with treatment during warmer seasons and in darker skin phototypes. Other adverse events were not observed in any patient.Patient satisfaction was highest in groups B1 and B2, where approximately 72% reported ‘excellent’ satisfaction. The lowest durability rate (16%) was observed in group A2, while the highest (72%) was seen in group B2, comparable with groups A1 and B1. Treatment tolerability was reported 100% in all groups.Conclusion: It was found that the modified Kligman formula outperformed microneedling‐TA alone. However, with optimal patient selection, particularly targeting those at lower risk for PIH with lighter skin phototypes and scheduling treatments during less‐sunny seasons, combining microneedling with 4% or 10% TA and the modified Kligman formula significantly enhanced efficacy and satisfaction rates compared to conventional topical treatment.