Covid Toes: What Are They and What Do They Mean

May 11, 2020

Within the past month, dermatologists and other physicians have started noticing an increase in patients complaining of reddish or purplish toes. We're seeing this skin condition mostly with young people in their 20s or 30s. Some patients say the condition developed slowly over a two-week period. Others are reporting they woke up with it.

The lesions look a lot like a skin condition called pernio or chilblains, which often presents as red/purplish patches or bumps on the toes that can occur after exposure to cold air or moisture. The skin lesions tend to be painful and itchy and sometimes blister. Pernio usually occurs during the fall or winter; that's why seeing this condition now, in the spring, is raising our eyebrows.

What's going on?

Because of the strange increase in these types of rashes in the context of the COVID-19 pandemic, dermatologists have dubbed this new phenomenon "COVID toes." We've seen just one toe affected, or sometimes multiple toes. Some patients have a similar condition on their fingers.

In most cases, we are observing that COVID toes are most frequently a late-stage symptom of COVID -19, meaning those with the skin condition probably have been asymptomatic until the skin condition started. The majority of the cases reported note that COVID toes appeared at the same time or after more common COVID-19 symptoms, rather than before. In some cases, COVID toes may be the only symptom someone ever has of COVID -19.

In general, the presence of COVID toes usually predicts a mild course of the virus, without serious, life threatening illness.

It's still too early to tell exactly why COVID toes appear, but we have some theories. One hypothesis is that COVID toes may be an immune response to the virus, which is creating very small blood vessel clots inside small vessel walls that create these rashes (vasculopathy). Another theory is that the coronavirus directly causes inflammation in the toe tissue and vessels.

When I see patients with skin changes that are consistent with COVID toes, I first assess whether they have any of the common COVID -19 symptoms: fever, shortness of breath or a cough. I also ask questions to find out if they've been directly exposed to COVID -19. If the answer to this question is yes, I'd likely recommend sending the patient for a COVID -19 test. If the answer to these questions is no – and that is usually the answer – I recommend they self-quarantine for 7-14 days from the onset of the rash.

The reason I counsel patients to self-quarantine is because the patient may in fact have COVID -19 and may be shedding the virus through his or her breathing and infecting others without realizing it. The U.S. Centers for Disease Control and Prevention describes self-quarantine as staying separated from others while limiting movement outside of the home. Self-quarantining helps limit the spread of COVID -19 in the community.

Usually, COVID toes resolve without any specific treatment, but some simple steps may help reduce the duration of the rash and the severity of the pain.

When a patient has COVID toes, I recommend:

  • Setting up a virtual visit with a dermatologist or primary care physician. The doctor can assess the condition and determine a treatment plan. The doctor may recommend COVID-19 testing, if warranted. 
     
  • Keeping feet warm by wearing either warm socks or applying a heating pad. This type of rash usually responds well to warmth. 
     
  • Calling your dermatologist or physician if the condition is worsening or not improving after a few days or if you develop other symptoms of COVID -19.

Dermatologists also are seeing some COVID -19 patients with petechiae, which are purple pinprick dots on the skin. Petechiae can be a sign of a low platelet count or can be brought on by a viral condition. If you notice purple small dots on your skin, contact your physician right away.

Palpable purpura – essentially, raised bruises -- can also be caused by COVID-19. Call your physician if you notice this on your skin.

Keep in mind that there are many, many reasons you may be noticing a rash on your body that have nothing to do with COVID-19. Skin conditions can be caused by other viruses, autoimmune disorders, allergic reactions, etc. The best way to know for sure is to contact your physician for an evaluation if you notice any new rashes on your skin.

 

Tola Oyesanya, MD, is a board-certified dermatologist with the Mid-Atlantic Permanente Medical Group. She sees patients at the Kaiser Permanente Towson Medical Center. Mid-Atlantic Permanente Medical Group, P.C. (Permanente) is our network of over 1,500 physicians who practice in our medical centers located in Maryland, the District of Columbia, and Virginia.

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