COVID toes

With more than eight million cases of COVID-19 worldwide at the time of this writing, we know there’s no universal COVID-19 rash. But there are a number of nonspecific cutaneous findings reported in individuals with COVID-19. 

These include hives, morbilliform and vesicular eruptions, as well as manifestations of occlusive vascular disease, such as livedo.

What are COVID toes?

Dermatologists worldwide have noted an uptick of cases of pernio-like lesions on fingers and toes. Pernio, also known as chilblains, is an inflammatory condition. It presents with erythematous to violaceous patches, papules, and sometimes vesicles on fingers and toes. 

Pernio is usually related to cold exposure, but some cases can be related to autoimmune disease. Many patients have no symptoms, but some have pain and/or itchiness in the affected areas. The rash can last from a few days to a few weeks.

More cases of pernio

Since the pandemic began, dermatologists have seen pernio-like lesions in higher numbers than usual, even in warm climates where pernio usually isn’t seen. There are hundreds of recently reported cases of suspected COVID-19-related pernio in the literature. 

Generally, reported patients are healthy and young (in their 20s or 30s). Many are children. About half reported possible COVID-19-like symptoms one to two weeks before the onset of the lesions or had close contact with someone who had COVID-19. 

Positive PCR and antibody tests in reported cases (and word of mouth among dermatologists) are quite rare, though testing of these patients has been limited. The few skin biopsies reported show findings consistent with common pernio.

Are new cases related to COVID-19?

It’s unclear if and how the increased frequency of pernio is related to COVID-19. Many dermatologists think pernio is a post-infectious phenomenon in patients with mild or asymptomatic COVID-19 and may portend a good prognosis. 

The fact that many pernio patients are testing negative also begs a few questions. Is it possible that it’s totally unrelated to COVID-19? Are current testing methods unable to detect this mild disease phenotype?

One recent paper reported seven cases of pernio among children ages 11 to 17. All tested negative via nasopharyngeal PCR. But in each case, SARS-CoV-2 viral particles were found in the endothelial cells of biopsy specimens from affected toes. 

This could suggest a pathogenic role of SARS-CoV-2 in COVID toes. We need to keep investigating these cases to learn more.

How to manage symptoms

If a patient comes to you with pernio now, do the following: 

• Patients with COVID-19 symptoms should be PCR tested and isolated per CDC guidelines.
• If the patient had COVID-19 symptoms that resolved before pernio began, do antibody testing in the appropriate time range for the test being used.
• If the review of systems is otherwise normal, a broad workup for underlying causes is probably not necessary.
• Tell patients to keep affected body parts warm and to dress warmly to ensure a normal core temperature. 
• If toes are symptomatic, a topical steroid can help reduce pain and itching.

Report COVID-19-related rashes

Please report any rashes in suspected or confirmed COVID-19 patients to the American Academy of Dermatology COVID-19 registry.

By Katrina Spaunhurst, MD, FAAD

The information provided is for general informational purposes only and is not intended to be medical advice or a substitute for professional health care. You should consult an appropriate health care professional for your specific needs.