What are Covid toes? Experts warn of five skin rashes that could be symptoms of infection
Multiple rashes, including what is being dubbed as “Covid toes,” are affecting some patients diagnosed with the new coronavirus, according to a report. The rashes can take many forms — some appear as small red bumps or pink or white raised areas of skin, while others look like frostbitten toes.
Rashes are currently not included in the list of symptoms for Covid-19. According to the US Center for Disease Control and Prevention (CDC), people with specific symptoms or combinations of symptoms may have Covid-19, which includes cough and shortness of breath or difficulty breathing. Or, they could have at least two other symptoms such as fever, chills, repeated shaking with chills, muscle pain, headache sore throat and loss of taste or smell. However, the CDC emphasizes that the list is not all-inclusive.
In the current study, five common skin manifestations of Covid-19 were identified by Spanish dermatologists. While it is not uncommon for a rash to be a symptom of a virus, such as the spots that indicate chickenpox, the researchers were surprised to see so many varieties of rash with Covid-19. All patients with an unexplained skin eruption in the last two weeks, and either suspected or confirmed Covid-19, using the definitions of the European Centre for Disease Control, were included. The total number of patients in the final sample was 375. A standardized questionnaire was used and pictures taken in most cases. An initial 120 images were reviewed by four dermatologists, without knowing any other clinical information and a consensus was reached on patterns of Covid-19's effect on the skin. These patterns were then applied to the rest of the images and further refined. The findings have been published in the British Journal of Dermatology.
The analysis shows that patients had “acral areas of erythema-edema with some vesicles or pustules” (pseudo-chilblain) in 19% of cases. These lesions, affecting hands and feet, may resemble chilblains (small, itchy swellings on the skin) with small red or purple spots, caused by bleeding under the skin. They are usually asymmetrical. The study says they are associated with younger patients, lasted for a mean of 12.7 days, took place later in the course of the Covid-19 disease and was associated with less severe disease (in terms of hospital admission, pneumonia, intensive care unit admission or mortality). They could cause pain (32%) or itch (30%).
The bruising and lesions being seen on the feet of some coronavirus patients have been dubbed as ‘Covid toe.’ And while Covid toes and rashes have been associated with the coronavirus more than other viral infections, Cleveland Clinic pulmonologist Dr Humberto Choi explained that these symptoms have not been widespread so far. Dr Choi says, like rashes, Covid toes are just another way that the body can respond to a viral infection.
“It’s a different form of manifestation and it is still not very clear what causes it. One pattern of Covid toes that people are reporting is red lesions typically on the soles. It’s possible that this is a skin reaction or caused by a small clog or micro clots in the blood vessels found in the toes,” says Dr Choi. He says that he has seen this before though with ICU patients with sepsis or people on life support. These clogs in the vessels can lead to discoloration in the toes, which is why Covid toes look the way they do, Dr Choi explained.
These symptoms seem to be more common in Covid-19 compared with all other viral infections,” says Dr Choi. “But at this time, they haven’t affected a majority of people. So, the symptoms that people should be looking for are really a fever, cough and muscle aches that you can get when you have a viral infection. Those are the most common symptoms — and those are the things that people should be keeping on their radar.”
In the Spanish study, the second type identified by medical experts includes vesicular eruptions (9%), which are outbreaks of small blisters, some of these presented on the trunk. They may also affect the limbs, may be filled with blood, and become larger or more spread out. These are associated with middle-aged patients, lasted for a mean of 10.4 days, appeared more commonly (15%) before other symptoms and were associated with intermediate severity. The third type is described as “urticarial lesions (19%)”, comprising pink or white raised areas of skin resembling nettle rash, known as wheals, which are usually itchy. They are mostly distributed in the trunk or spread across the body, but a few cases were on the palms of the hands.
The researchers also identified maculopapules (47%) in patients. They are small, flat, and raised red bumps. In some cases these were distributed around hair follicles, there were also varying degrees of scaling. Some had been described as similar to pityriasis rosea, a common skin condition. Blood spots under the skin may also be present, either in the form of spots/dots or on larger areas. They lasted for a shorter period (6.8 days mean for urticarial and 8.6 for maculopapular), usually appeared at the same time than the rest of the symptoms, and were associated with more severe Covid-19 disease (2% mortality in the sample).
The fifth type is being referred to as livedo or necrosis (6%). It is a skin condition where circulation in the blood vessels of the skin is impaired and causes the skin to take on a blotchy red or blue appearance with a retiform (net-like) pattern. “Necrosis refers to the premature death of skin tissue. These patients showed different degrees of lesions suggesting occlusive vascular disease, where a narrowing or blocking of arteries occurs, limiting blood flow to certain areas of the body (in this case the trunk or extremities). They were associated with older patients with more severe disease (10% mortality). However, the manifestations of Covid-19 in this group were more variable, including transient livedo, with some suffering Covid-19 that did not require hospitalization,” says the report.
Meanwhile, some researchers have also published individual case studies. A report described the case of a man in Spain who developed “petechial skin rash” or tiny red dots on the skin. Another report described a patient in France who developed larger lesions known as a “digitate papulosquamous eruption.” Both case studies have been published in JAMA Dermatology. Another report warned of “pseudo-frostbite of the extremities and transient hives,” and urged patients with such skin problems to consult a dermatologist. A report in the Journal of the American Academy of Dermatology detailed purplish lesions on the feet of a 23-year-old coronavirus patient in Belgium. The American Academy of Dermatology is also compiling a register of skin symptoms seen by its members. This survey is for all health care professionals taking care of Covid-19 patients who develop dermatologic manifestations or dermatology patients with an existing condition who then develop Covid-19.
Unclear if rashes are directly caused by Covid-19
Some scientists say that it is too early to say whether these rashes are directly caused by the new coronavirus, or whether they are related to other factors. Experts also say that skin lesions and rashes are common and on their own should not necessarily be a cause for concern. Expertise is needed to identify the skin symptoms described in the Spanish study, they add.
“Whether rashes are specific manifestations of SARS-CoV-2 infection involving the skin or represent reaction patterns in association with Covid-19 is an important question to keep in mind when evaluating these images. We must be cautious in attributing all rashes seen in patients with Covid-19 to direct effects of SARS-CoV-2; rashes may develop because of co-infection with SARS-CoV-2 and another respiratory infection, medical complications that arise in a critically ill patient (such as fever or disseminated intravascular coagulation), or other supportive medications or empirical treatments for infection,” write experts in JAMA Dermatology.
They add, “The reported prevalence of cutaneous signs in association with this pandemic is conflicting; one study reported a rash in only 0.2% of a cohort of Chinese patients, whereas the estimated prevalence in a cross-sectional Italian study was 20.4%.”
According to Dr Choi, it is quite common for people to get rashes when people are battling this type of infection, especially viral respiratory ones. “It’s not uncommon for someone to have a viral infection and have a rash or blotchy areas on their body. This can happen with other viral respiratory infections like measles. And sometimes, antibiotics might cause skin rashes,” said Dr Choi.
The Spanish researchers also said that some of the skin rashes associated with Covid-19 are common and can have many causes, particularly maculopapules and urticarial lesions. “It is hard to tell if they are directly caused by Covid-19, or simply indicate complications. For these reasons, people should be very cautious about trying to self-diagnose Covid-19 based on skin symptoms,” cautioned experts.
The CDC recommends consulting the doctor for any other symptoms that are severe or concerning to an individual. “During the pandemic, when someone has a specific symptom and they’re wondering whether that could be from Covid-19, my best advice would be to get tested,” said Dr Choi.