“We feel strongly these symptoms are connected to the virus,” says Lindy Fox, MD, a dermatologist and a professor of clinical dermatology at the University of California in San Francisco and a member of the COVID-19 task force at the American Academy of Dermatology (AAD). When it began to appear that the surprising, strange-sounding symptom might be a sign of COVID-19, dermatologists at the AAD formed the task force to compile and analyze cases of the condition. “Most of the evidence is anecdotal, although there is growing consensus in the medical community that the lesions that are occurring can’t be just a coincidence,” says Velimir Petkov, DPM, a doctor of podiatric medicine at Premier Podiatry in Clifton, New Jersey. RELATED: Why You Shouldn’t Skip Your Dermatology Appointment During COVID-19 Doctors in Europe noticed that these pernio-like red bumps and lesions were starting to show up on the toes — and sometimes hands — of certain people who tested positive for COVID-19. “When Spain and Italy had their initial coronavirus outbreak, dermatologists started to talk about the symptoms they were seeing on patients’ toes, and American dermatologists were then connected with European dermatologists,” says Dr. Fox. “Then we started to see more patients with these same pernio-like lesions in the United States.” European podiatrists picked up on the trend. “Podiatrists in Spain reported that mainly children and adolescents had some dermatological lesions on their feet and toes, sometimes in the absence of other COVID-19 symptoms,” says Dr. Petkov. While pernio isn’t unusual, Fox says what’s surprising is that the patients got these pernio-like lesions after the colder months had already passed in Spain and Italy. The fact that the spontaneous spike in occurrences paralleled the coronavirus pandemic also raised alarms. “We are seeing an astonishing number of pernio cases, and also not during the right time of year, which makes this unusual," says Fox. “If they’re seeing it in Europe because of COVID-19, then we are likely here, too.” RELATED: What’s Causing Your Skin Rash? It’s worth noting that skin reactions often come along with viral infections. “We see skin rashes, including similar lesions on the hands and feet, with other viruses, so it is not surprising that patients infected with COVID-19 would have skin rashes, too,” says Melissa Piliang, MD, a board-certified dermatologist at the Cleveland Clinic in Ohio. Not to mention that skin rashes could be caused by several other factors, such as contact dermatitis, from exposure to irritants including laundry detergent and cleaning chemicals, or allergens like cosmetics or fragrances, notes the Cleveland Clinic. COVID toes differ in that they occur in the absence of these triggers, and are located primarily on the toes and fingers (contact dermatitis could, for example, show up anywhere, notes the Mayo Clinic). “To a dermatologist, they look quite different,” says Dr. Piliang. “COVID toes are red-purple nodules,” she says. “The overlying skin may be discolored, but at least initially, is not affected, and later, as the lesions heal, the skin may peel. The lesions of COVID toes may feel hot or tingly and are often sore or tender, and the lesions come up very suddenly.” In contrast, says Piliang, allergic contact dermatitis has changes to skin surface. “There may be blisters and often the surface weeps fluid, and there is scale crust on top,” she says. Plus, contact dermatitis is generally very itchy and may have stinging sensation but is generally not tender or painful like COVID toes, notes Piliang. The American Academy of Dermatology has since started a registry for doctors to log COVID-19 patients with skin symptoms, and is currently running a study on the data, says Fox. Doctors seeing patients with COVID-19 can upload information such as the patient’s age, ethnicity, location, COVID-19 test results, and any skin rashes to this registry, says Piliang. “As the number of reported patients grows, researchers can go back to this data and try to determine how frequently different skin rashes such as COVID toes occur in patients with COVID-19,” says Piliang. For now, it’s unclear how many people with COVID-19 have COVID toes. Patients’ medication lists are also being collected in the registry, in case those may be playing a role in the skin symptom. “We are interested in how patients on biologic medications or other treatments for skin disease fare with the virus,” says Piliang. RELATED: Scientists Fast-Track Research for Coronavirus Treatment and Vaccine COVID toes in this instance is very different from the unrelated purple toe problem that can affect people in critical condition with COVID-19, Fox notes. One small study out of China looked at seven critical COVID-19 patients, and found that all patients had “finger/toe cyanosis,” which is often due to a blood circulatory problem, according to the NHS. Doctors are now predicting that COVID toes is actually a potential sign that your body has successfully fought the virus. “The symptom typically happens at a later stage of the virus, during the recovery phase, though it can happen earlier, too,” says Fox. The good news? “People are generally out of the woods if they do have this symptom — their body has seen COVID-19, has had exposure, and they’re not going to have severe disease,” adds Fox. “In this case, it should be a reassuring sign.” Still, COVID toes come with some discomfort. People may have painful, burning, or itchy bumps or a rash on their toes that can last for a week — though some unlucky patients can experience it for up to three to four weeks, says Fox. As for treatment, there aren’t any proven remedies. “Usually the skin will heal on its own — eventually,” says Fox. For management of COVID toes, some dermatologists are recommending aspirin to their adult patients because it can break up the small clot of blood that they think is causing the pernio. For itch, some are prescribing strong topical corticosteroids, such as Tomeval (clobetasol). RELATED: Allergies or COVID-19? Here’s How to Tell the Difference “The simple prediction is that it’s an activation of the immune system that causes these symptoms, in response to the virus,” says Fox. And a longer potential explanation: “We think that COVID toes are occurring due to clamping down of the small vessels in the fingers and toes,” says Piliang. This inflammation may damage the vessels directly — called vasculitis — or may be due to small clots forming in the vessels, she says. And as for why younger, healthier people with COVID-19 might account for more instances of COVID toes? “A younger person has a healthier immune response, which can protect them from worse reactions to the virus, but it’s the active immune system that triggers this response,” suggests Fox. “With older people, the immune reaction is not as robust, so this response isn’t likely triggered,” she says. Research is ongoing, and dermatologists are in the early stages of data collection. “With our American Academy of Dermatology registry, any healthcare worker in the world can submit a case, so we can collect the data and try to come up with guidelines that can help people,” says Fox. RELATED: A Coronavirus Checklist: Prepare for the Possibility You May Get Very Sick If a dermatologist suspects it’s COVID toes, which would be an indicator of COVID-19, ideally they would be able to recommend you get a coronavirus test as well as an antibody test, says Fox. “Hopefully more awareness about this symptom will change the COVID-19 testing criteria for who is eligible for a test,” says Fox. Patients should, however, remember that an allergic reaction could mean you have something entirely different from COVID-19. “Maybe you had a strawberry and you’re allergic — people get skin reactions all the time, and in this case it could be COVID or it could be something totally different, and that’s important to remember,” says Debra Wattenberg, MD, a dermatologist and an associate professor of dermatology at Mount Sinai, in New York City. Still there’s a big payoff in talking to your doctor if you think something may be up with your toes. “Identifying and isolating people with subtle cases of COVID may help diminish the spread of the disease,” says Piliang. And that’s something everyone can get behind.
