COVID-19 Resource Center

COVID-19 Resource Center

May 14, 2020
5 min read

'COVID-toes,' tracking dermatological symptoms of COVID-19

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Esther E. Freeman

As the world continues to struggle with the COVID-19 pandemic, new symptoms of the virus continue to be identified. One such symptom, purple or red lesions on the toes and hands, has been dubbed “COVID toes” and has gained attention over recent weeks.

Healio spoke with Esther E. Freeman, MD, PhD, director of global dermatology at Massachusetts General Hospital, Harvard Medical School, and a member of the American Academy of Dermatology’s COVID-19 task force, about what dermatologists should look for in patients with COVID-19, how to address dermatologic symptoms and a new registry from the AAD tracking COVID-19’s dermatologic symptoms.


Q. How did the idea of a dermatology-related registry for COVID-19 symptoms begin?

A. Even before we started hearing any reports about dermatologic manifestations of COVID-19, we were wondering about how we could better understand what would happen to our existing dermatologic patients who contracted Covid-19. In particular, we were concerned about patients who were on biologics, or those with preexisting dermatologic conditions such as psoriasis, eczema or lupus, to name a few. We appreciated collaboration from the Global Rheumatology Alliance, who had launched a similar database for Rheumatology and helped share their experience with us. While we were building the registry, we started hearing more and more reports about different skin manifestations in COVID-19, and we realized the registry was capable of collecting all of this data at the same time.

In terms of viruses and their effect on the skin, in dermatology we are used to viruses causing different viral rashes and eruptions. It was certainly not out of the ordinary for any of us to think there may be some viral rashes that we would end up seeing with COVID-19, like we see with many other viruses. But what has been more surprising is these increasing reports around these pernio-like lesions of the toes.

COVID-toes as seen in a teenage patient.
As the world continues to struggle with the COVID-19 pandemic, new symptoms of the virus continue to be identified. One such symptom, purple or red lesions on the toes and hands, has been dubbed “COVID toes” and has gained attention over recent weeks.

Q. What are COVID toes, and what should patients do if they notice them?

A. Pernio, a condition where you get red or purple tender bumps on the fingers or toes, also known as chilblains, is usually a reaction to cold temperatures. In COVID-19, I prefer to call it “pernio-like” rather pernio, since we don’t yet know if it’s truly the same process. A lot of these patients adamantly deny being exposed to any sort of cold temperatures whatsoever. These skin lesions have been dubbed “COVID toes.”

What patients are experiencing are red or purple bumps on their toes or hands, as well as a burning sensation, often with pain and tenderness. The good news is it seems to go away after about 2-3 weeks.

For the most part, we have seen this in young and relatively healthy patients, both in children and adults. So, I want to emphasize I do not want people to panic and think “Oh I have purple toes, I’m going to go on a ventilator.” While we have had a few reports of sicker patients that have developed this finding, for the most part, that is not what we have been seeing.

I recommend concerned individuals contact their board-certified dermatologist or their primary care doctor to discuss if they are concerned about new onset of toe lesions. There are other conditions that can cause something similar, so you will want someone to evaluate you and go through a thorough medical history.

Q. What should dermatologists be on the lookout for in terms of COVID toes, or how should they react when patients report them?

A. One of the challenges around these lesions is that our knowledge is continuing to evolve around how we counsel patients regarding quarantine at this time. People should be following CDC and local guidelines in terms of self-isolating, regardless. We know that some patients who develop the pernio-like lesions of their feet are still infectious, because they are testing PCR positive for the virus. This means that there is a potential risk of transmitting the virus to others. It seems that some people may develop these lesions while they are still infectious, while others may develop them somewhat later in the disease course. We need more data on the timing of these pernio-like lesions so we can better guide our providers on how to counsel their patients. That is an area we are actively working on.

This has public health implications because if your patient is potentially still infectious when their toes are purple, that is a different story than if they are not infectious and they are already basically over the infectious stage of the virus.


Q. What other dermatologic manifestations are being reported in patients with COVID-19?

A. COVID toes are kind of stealing the spotlight, but about half our registry is conditions other than these pernio-like lesions of the feet and hands. We are seeing other virally induced rashes and eruptions such as morbilliform, also known as measles-like eruptions, and urticaria, also known as hives, among many others.

One of challenges is that patients with COVID-19 are often on multiple medications, and so when a rash develops it can be hard to sort out whether the skin findings are related to a medication or to the virus itself.

Q. What is the Dermatology COVID-19 registry, and what are its main goals and objectives?

A. It is an international registry, with data housed at Massachusetts General Hospital, in collaboration with the American Academy of Dermatology and the International League of Dermatology Societies.

The first goal is to collect dermatologic manifestations of COVID-19. Right now, we are collecting both lab-confirmed cases and suspected COVID-19 because we recognize that patients do not always have access to testing. We stratify registry analysis based on whether people have had laboratory confirmation of the virus or not.

The second group of patients we are interested in are those who have preexisting dermatologic conditions. We are interested in what happens to those patients if they develop COVID. We are collaborating with a number of disease-specific registries around the world in this particular area.

The third group is made up of patients on existing dermatologic medications, for example biologics, immunossuppressives, or other dermatologic medications such as isotretinoin, who then develop COVID-19.

Q. What are some of the registrys limitations?

A. The registry is essentially a giant case series. It is not a large epidemiologic study, a cohort study or a case control study. We will not be able to tell the incidence or prevalence of any of these dermatologic conditions. I cannot look at this cohort and tell you, “X percent of COVID patients will have dermatologic findings.”

The registry is helpful for hypotheses generation and for people reporting unique findings. We are able to collect cases from around the world, but it has its limitations in that we cannot assign causation.

Q. How would someone use the registry?

A. It is a health care provider-facing database. This means we ask that patients do not enter their own information. You do not have to be a dermatologist to enter the information; we are also taking reports from healthcare providers from any field, which includes front-line health care providers or primary care doctors who are taking care of COVID patients.

Entering a case takes about 5 minutes. It is de-identified. There is no protected health information that goes into the registry, and the data are securely housed in the REDCap platform at Massachusetts General Hospital. We appreciate all of our colleagues that have already entered cases. We are all learning about the effects of this virus together.

Information can be added at – by Rebecca L. Forand


Disclosures: Freeman reports no relevant financial disclosures.