'COVID Toes' and Other Skin Conditions Tied to Coronavirus

Northwestern Medicine
Dermatology April 20, 2020
Attribute to: Jill K. Cotseones, DO, FAAD, medical and cosmetic dermatology at Northwestern Medicine Central DuPage Hospital

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What are “COVID toes”?
COVID toes is the term being given to red-purple toes that have been reported in patients that are COVID-19 positive. They have been reported in both children and adults and do not typically correspond to the severity of the COVID infection. Typically “COVID toes” involves 1-3 digits (either fingers or toes) and presents as red-purple to blue skin lesions that are often painful. They have a very similar appearance to pernio, which is a skin condition that often develops after exposure to cold temperatures. It is important to recognize that COVID toes typically precede the onset of systemic symptoms of the virus and may be the only symptom the patient presents with during a COVID infection. As the infection progresses, the skin lesions can blister or form a crust on the skin.

What are some possible causes?
A lot is unknown about the virus, but we are finding out more each day. We know that there is an increased risk of vascular occlusive phenomena or clotting in very sick patients with COVID-19. We suspect that this is secondary to the extreme immune response triggered by the virus which may result in damage to the lining of the blood vessels and clot formation. As a result, this may theoretically lead to decreased blood flow of the acral skin surfaces; although further investigation is warranted.

What are some possible treatments?
COVID toes are typically self-limited, and resolve as the infection clears with no treatment necessary. If very painful or symptomatic, topical corticosteroids have been used anecdotally to improve the skin lesions more quickly. More importantly, “COVID-toes” may be a red-herring that you have an infection with COVID-19 and if exhibiting the acute onset of these skin findings, viral testing may be warranted.

Are you seeing other types of skin conditions as a result of COVID-19?
Other skin manifestations being reported from COVID-19 are a net-like red rash on the extremities called livedo reticularis, hives, petechiae (an eruption typically seen with low platelets), and a chicken-pox like eruption on the body.

Is there any reason for concern about these conditions long-term?
Not all red-purple toes are “COVID toes” and should be evaluated by a physician or board-certified dermatologist, particularly if they persist or worsen. Similar skin lesions can be associated with chronic autoimmune or vascular disease, infection, or be suggestive of a medication reaction.

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