COVID-19 Manifestation in Toes

Expert Author
Jillian Irwin Podiatrist (Foot and Ankle Specialist) Manhasset, NY

Dr. Jillian Irwin is a podiatrist practicing in Manhasset, NY. Dr. Irwin is a medical doctor specializing in the treatment of the foot, ankle, and related parts of the leg. As a podiatrist, Dr. Irwin diagnoses and treats conditions of the feet. The feet are key body parts that give a person stability, absorb shock, allow... more

By Jillian Irwin, DPM

Podiatric Physician at North Shore Podiatry, P.C.

On the day I’m writing this article the number of reported COVID-19 cases in Nassau County alone has reached over 211,000 with 44.1 million cases reported in the United States alone. The virus has spread far and wide over the past year and a half. Physicians and research experts have worked fervently to better understand the novel virus and they have published preliminary information followed by consistent updates as the pandemic progresses. We are gaining a greater understanding of the virus, the disease it manifests in people, and how to best treat and prevent the spread of the virus. 

“COVID toes”

Skin changes have been observed in patients affected by SARS-CoV-2 have reported skin lesions, specifically located in the feet and toes. Patients have noted red-violet or in extreme cases black ischemic changes to the toes. In addition, some have reported pain, swelling, and/or itching in those areas of discoloration (1). Histopathology has demonstrated that the virus itself can cause damage to the endothelium (the inner lining) of the blood vessels (2). This damage to the small vessels can cause inflammation, bleeding under the skin called a hematoma, or even reduced circulation to the toes.  

This causes what is described as a “chilblains” appearance of the toes. Chilblains are a condition of inflammation and damage to the local blood vessels causing this damage and swelling to the area. It is often triggered by cold temperatures but systemic disease and chronic conditions can also cause chilblains also known as pernio. 

Who gets these symptoms?

Initially, there did not appear to be a correlation between the severity of coronavirus disease symptoms and the presence or absence of skin manifestations. However, recent studies have shown patients with “COVID-pernio” of the fingers or toes tend to have a mild illness related to the virus (3). Dark or black-appearing toes however are associated with patients who have a severe infection. Many patients experience skin manifestations associated with COVID-19 after recovering from the disease, while some notice skin symptoms while still symptomatic with the respiratory disease (4). Few patients testing positive for coronavirus experience the skin changes as their only symptom, with no associated fever or cough. Skin manifestations have been reported not just in the toes, but in the eyes, trunk, hands, and buttocks. On average younger patients with SARS-CoV-2 were reported to have “COVID toes” with the median age of 25 (3).

If my toes look like this, do I have COVID-19?

A purple, red, blue, and swollen skin appearance on your toes may not be due to coronavirus. Other viral diseases, chilblains, lupus erythematosus, vasculitis, pernio unrelated to Coronavirus, or connective tissue disorders could lead to such changes (1). In fact, the explanation could be simpler: Recent exposure to cold temperature, ill-fitting shoes, or reaction to a dye in new socks are potential causes. It’s important to protect yourself and others and get tested if you present with any symptoms of COVID-19. If you are noticing a new change in the appearance of your toes, see your podiatrist.

References

  1. Nirenberg MS, Del Mar Ruiz Herrera M. Foot Manifestations in a COVID-19 Positive Patient: A Case Study. J Am Podiatr Med Assoc. 2020 May 4. doi: 10.7547/20-088. Epub ahead of print. PMID: 32366113.
  2. Colmenero I, Santonja C, Alonso-Riaño M, Noguera-Morel L, Hernández-Martín A, Andina D, Wiesner T, Rodríguez-Peralto JL, Requena L, Torrelo A. SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases. Br J Dermatol. 2020 Oct;183(4):729-737. doi: 10.1111/bjd.19327. Epub 2020 Aug 5. PMID: 32562567; PMCID: PMC7323219.
  3. Cappel MA, Cappel JA, Wetter DA. Pernio (Chilblains), SARS-CoV-2, and COVID Toes Unified Through Cutaneous and Systemic Mechanisms. Mayo Clin Proc. 2021 April;96(4):989-1005. doi:10.1016/j.mayocp.2021.01.009
  4. Seirafianpour F, Sodagar S, Pour Mohammad A, Panahi P, Mozafarpoor S, Almasi S, Goodarzi A. Cutaneous manifestations and considerations in COVID-19 pandemic: A systematic review. Dermatol Ther. 2020 Jul 8:e13986. doi: 10.1111/dth.13986. Epub ahead of print. PMID: 32639077; PMCID: PMC7362033.