The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has led to a wide array of symptoms and complications, some of which were previously unknown to both the medical community and the general public. Among these, “COVID toes” emerged as a peculiar dermatological manifestation, drawing attention from clinicians, researchers, and patients alike.
Clinical Features of COVID Toes
COVID toes refer to a set of skin changes affecting the toes (and sometimes fingers), most commonly characterized by redness, swelling, and purplish discoloration. These lesions are often similar in appearance to chilblains (pernio), a condition typically associated with cold exposure. COVID toes can present with:
- Red or purple discoloration of the skin
- Swelling and tenderness
- Blistering or ulceration in severe cases
- Itching, burning, or pain
- Sometimes, the skin may become dry and peel as the lesions resolve
While most commonly seen in the toes, similar changes have been reported on the fingers, leading to the broader term “COVID-associated chilblain-like lesions.”
Who Gets COVID Toes?
COVID toes have been observed in both children and adults, though reports suggest they are more common in younger, otherwise healthy individuals. They may appear in people with confirmed COVID-19 infection, as well as in those who never test positive but have had possible exposure. The lesions typically develop several days to weeks after the initial infection or exposure, sometimes even when other COVID-19 symptoms are absent.
Mechanisms and Pathophysiology
The exact cause of COVID toes is still under investigation, but several mechanisms have been proposed:
- Immune Response: One leading theory is that COVID toes are the result of a robust immune reaction to the virus. This may cause inflammation of small blood vessels in the skin, leading to the observed changes.
- Microvascular Injury: COVID-19 is known to affect blood vessels, sometimes causing clotting and microvascular injury. These changes could disrupt blood flow to the extremities, resulting in skin discoloration and swelling.
- Direct Viral Effects: There is some evidence that SARS-CoV-2 may directly infect cells in the skin or blood vessels, though this is less well established.
- Genetic and Environmental Factors: Not everyone with COVID-19 develops these lesions, suggesting that genetic predisposition or environmental factors may also play a role.
Diagnosis
Diagnosis of COVID toes is primarily clinical, based on the appearance of the lesions and the patient’s history of COVID-19 exposure or symptoms. Laboratory tests, such as PCR or antibody testing for SARS-CoV-2, can help support the diagnosis but are not always positive at the time the lesions appear. In some cases, a skin biopsy may be performed to rule out other causes and to study the microscopic features, which often show inflammation around blood vessels and signs of vascular injury.
Prevalence and Prognosis
The true prevalence of COVID toes is uncertain, as not all cases are reported and many patients with mild skin symptoms may not seek medical attention. However, published case series from various countries suggest that these lesions are relatively uncommon compared to other COVID-19 symptoms. Most cases are mild and resolve on their own within a few weeks, often without the need for specific treatment. Severe or persistent cases are rare.
Implications for Patients and Healthcare Providers
For patients, the appearance of COVID toes can be alarming, especially if they occur in the absence of other COVID-19 symptoms. However, the prognosis is generally good, and most people recover fully. Healthcare providers should be aware of this manifestation, as it may be the first or only sign of COVID-19 in some individuals. Recognizing COVID toes can help identify cases, prompt testing, and guide isolation or infection control measures.
COVID toes are a distinctive skin manifestation associated with COVID-19, characterized by chilblain-like lesions on the toes and sometimes fingers. While the exact cause remains under investigation, they are believed to result from immune-mediated inflammation and microvascular changes related to SARS-CoV-2 infection. Most cases are mild and resolve spontaneously, but their recognition is important for early identification and management of COVID-19. As our understanding of the pandemic evolves, so too does our knowledge of its varied and sometimes unexpected effects on the human body.
