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What Are "COVID Toes"?

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An increase in the number of patients experiencing toe swelling and discoloration during the coronavirus (COVID-19) pandemic, led dermatologists and researchers to speculate that it could be linked to a mild COVID-19 infection. The phenomenon—which is harmless and most commonly seen in children and adolescents—earned the nickname COVID toes. The condition typically resolves within a few weeks and symptoms include one or more toes (and sometimes fingers) that turn pink, red, or purplish.

While some small studies suggest a possible link between the toe symptoms and COVID-19, a direct connection has not been established and more research from larger studies are needed.

The Centers for Disease Control and Prevention (CDC) does not currently include toe discoloration or toe pain as a potential symptom of COVID-19.

“We’re seeing—one might say an epidemic—of what someone termed ‘COVID toes,’” Amy Paller, MD, chair of the department of dermatology at Northwestern University Feinberg School of Medicine tells Verywell Health. “We don’t yet really understand the relationship to COVID-19. It’s just an observation that we’re making with unprecedented numbers at a time where there’s a pandemic, so we think it may be a sign of mild disease.”

COVID Toes Symptoms

COVID toes resembles a rare skin condition called pernio (also known as perniosis or chilblains), an inflammatory skin condition caused by over-exposure to cold and damp temperatures. Pernio is a form of vasculitis (inflamed blood vessels) that can lead to discoloration and/or swelling on the hands or feet.

Pernio can also occur as a secondary condition in those with autoimmune diseases, connective tissue disorders, blood cancers, or other types of viral illnesses, such as Epstein-Barr virus. This form of pernio is more likely to occur in adults than children.

COVID toes, which either mimics pernio or is a form of pernio, most commonly affects one or more toes and/or the feet. It can also sometimes involve the hands or fingers. Symptoms include:

  • Discoloration that’s pink, red, purple, or that progresses from red to purple 
  • Swelling that may or may not be itchy, burning, tender, or painful

Additional symptoms of COVID toes may include:

  • Raised bumps or areas of rough skin
  • Blisters
  • Brownish purple spots
  • Small amounts of pus

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Potential "COVID Toes"
Potential "COVID Toes". Photo courtesy of Dr. Amy Paller, Northwestern University

The condition seems to last anywhere from 10 days to months. 

Causes

The skin condition, especially in children, is associated with the emergence of the COVID-19 pandemic, but whether or not it is actually connected to COVID-19 is still undetermined.

The research on COVID toes is mixed. Some small and preliminary studies have linked COVID toes to current or previous COVID-19 infection through testing, including for COVID-19 antibodies, or household contacts. Other research has not found evidence of COVID-19 infections.

Some researchers have suggested an uptick of pernio due to cold exposure, such as walking barefoot or with thin socks at home, in predisposed individuals who are in quarantine or staying home.

A review published in the journal Clinics in Dermatology found that most children and adolescents were asymptomatic or reported mild COVID-19 symptoms prior to developing the skin condition. One study also found increases in production of interferon, a type of cytokine (signaling proteins) secreted by cells in response to viral infections, in those with COVID toes even if they tested negative for active COVID-19 infection and for antibodies.

Many researchers suspect that COVID toes occurs late in the disease progression and some suspect that COVID-19 tests can be negative because the virus has already cleared to undetectable levels.

The review also found that the lesions appeared in various countries at a similar time point in each country's curve and was weeks after a country reached a peak of infection. Whether this is connected to COVID-19 infection, occurs due to behavioral changes while staying home, or is due to another viral illness or something else entirely is unclear.

“What I really think it could be is the mild end of the COVID-19 spectrum in individuals who have a brisk immune response,” Paller says. In other words, it’s possible that the person has or had a COVID-19 infection, and red or purple toes is their only symptom. 

“Is that just because it’s too late in the disease spectrum by the time it shows up in the toes? Is it that their case is so mild they have a very low viral load and a test just can’t pick it up easily? There are lots of theories out there, but we just don’t know,” she says.

Diagnosis

Your doctor will want to do a personal and family medical history to check if there are any underlying conditions or other types of recent infections that would increase your risk of pernio. They will also ask about any cold exposures or behavioral changes and if you've had any recent symptoms of COVID-19 or been in contact with anyone diagnosed with COVID-19.

Common symptoms of COVID-19 are fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.

Your doctor may recommend COVID-19 diagnostic tests if you develop symptoms of COVID toes, especially if you were in contact with someone who tested positive for COVID-19 or you have or recently had symptoms of COVID-19.

Depending on your risk factors and other symptoms, your doctor may also want to do some testing for potential underlying conditions, especially if the skin condition recurs.

Treatment

If you experience pain, itching, or burning on your toes or fingers, there are over-the-counter or prescription medications that your doctor may recommend or prescribe.

If your toes are itchy or tender, treatments may include:

  • Hydrocortisone cream
  • Topical corticosteroids
  • Topical antihistamine

Over-the-counter hydrocortisone cream is a good first step to soothe COVID toes. If itching, pain, or swelling continues or worsens, contact your doctor. You may be prescribed a medium-strength topical corticosteroid or a topical antihistamine.

If your toes are painful, additional treatments may include: 

To learn more about how—and if—COVID-19 can manifest as a rash like COVID toes, the American Academy of Dermatology has created a registry for any healthcare provider to log cases of patients with skin symptoms who have either confirmed or presumptive cases of COVID-19. Their findings will be able to help determine how common COVID toes actually are.

Prognosis

Studies report that the condition typically resolves or nearly resolves within a few weeks and can last up to about two months.

“Everybody does tend to have a pretty satisfactory outcome,” Paller says of her patients. “COVID toes doesn’t damage. There might be a little discoloration at the end, but nobody’s losing toes because of this.”

A Word From Verywell

If you think you or a loved one may have COVID toes, contact your physician for guidance. You may need testing or your household may need to quarantine depending on your situation.

Regardless of whether or not it is related to COVID-19 infection, it will likely resolve on its own or with minimal treatments.

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Article Sources
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