Patient Buzz: Are COVID Toes a True Symptom of COVID-19?

USA TODAY and countless other media outlets have recently covered a dermatological phenomenon called COVID toes. Are COVID toes a true skin manifestation of COVID-19?

For an expert opinion, I consulted dermatologist Amy McMichael, MD, professor and chair of the department of dermatology, Wake Forest Baptist Medical Center, Winston-Salem, N.C.

What should dermatologists know about COVID toes?

One of the main concerns with COVID toes is that they are often the only or an early symptom of the virus. They are persistent red to purple itchy areas on the toes only accompanied by swelling of the toes. COVID toes are now recognized as a very important part of the constellation of signs we are learning about with the novel coronavirus.

How can dermatologists diagnose COVID toes?

COVID toes can and most often are diagnosed clinically by examination of the toes and the surrounding skin. If there is any concern about the diagnosis, biopsies of the skin can be performed that show damage to the small vessels of the skin, likely due to damage of ACE2 on the endothelial cells of skin.

Why do you think the body, in some cases, reacts in this manner?

We are still trying to understand all the ways the COVID-19 virus affects the skin. For now, it is thought that the virus sets off a cytokine storm that causes dysregulation of the immune system. This is accompanied by effects on the small vessels in the skin, which lead to the ultimate damage of the blood vessels. It is not clear why some patients develop this clinical condition and others do not.

How should a dermatologist respond if a patient presents with COVID toes?

Dermatologists need to step up and recommend viral testing for any patients for when the initial presentation is COVID toes and testing has not yet occurred. If the patient is already admitted to the hospital with a known diagnosis of COVID-19, dermatologists can help as consultants to recommend supportive therapy of the condition with topical steroids. The condition resembles pernio, which is caused by cold exposure. While it is not clear if warming will help COVID toes, this can be tried as well. The efficacy of anticoagulation has not been shown in this condition.

Image Credits

COVID Toes image courtesy of Dr. Adam Friedman

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