Adding to the list are other manifestations of the virus including the gastrointestinal, nervous, dermatological, and cardiovascular systems. The dermatological symptom of COVID-19 like rashes and discoloration appear on the toes and fingers. Skin lesions could be a typical indicator of COVID-19 infection in asymptomatic and mildly symptomatic individuals.

The patterns of acral lesions that occur on the toes are referred to as COVID toes. These lesions are described to be erythematous to purple papules or vesicles. COVID toes in children and young adults are the most common and appear in cases of mild to severe virus infection(2 Trusted Source
Hernandez, C., & Bruckner, A. L. (2020). Focus on “COVID Toes”. JAMA dermatology, 156(9), 1003.

Go to source, 3 Trusted Source
Jimenez-Cebrian, A. M., Castro-Mendez, A., García-Podadera, B., Romero-Galisteo, R., Medina-Alcántara, M., Garcia-Paya, I., Páez-Moguer, J., & Córdoba-Fernández, A. (2021). Clinical Manifestations of COVID-19 in the Feet: A Review of Reviews. Journal of clinical medicine, 10(10), 2201.

Go to source).


The COVID rash could appear in different forms and not all patients infected with COVID-19 would experience skin lesions. COVID toes can occur like any of the following types: itchy bumps, large and small patches, flat spots along with raised bumps, patchy rashes, chickenpox-like blisters, round spots, and lace-like patches on the skin(4 Trusted Source
COVID Toes, Rashes: How the Coronavirus can Affect Your Skin

Go to source). There is no consensus available on the types of COVID toes.

However, the acral lesions in COVID infection are grouped into two, the pseudo chilblain or the pseudo perniosis and livedo or necrosis. The pseudo chilblain is seen commonly in young people and during the later course of the disease while the livedo is common among older people with co-morbidities(5 Trusted Source
Ozbey, R., & Algan, M. F. (2022). Acro-ischemic lesions in COVID-19 patients: A case series. Journal of cosmetic dermatology, 10.1111/jocd.14893. Advance online publication.

Go to source).


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The possible causative factor of dermatological manifestations similar to chilblains is doubted to be the COVID-19 virus itself. Thrombosis (clotting) and vascular injury caused by the virus could be the reason for the clinical features in patients with COVID 19. Vascular injury may occur due to endothelial dysfunction caused by the direct viral infection or may also be immune-mediated. Some case studies have reported a pattern of tissue damage in the skin which could have resulted in symptoms of COVID toes.

The presence of the virus (SARS-CoV-2) particles in the endothelial cells suggest that the virus could be the direct causative agent of vascular damage and thrombosis. Thus, the virus-induced vascular damage could be the key mechanism behind the pathogenesis of COVID toes(6 Trusted Source
Colmenero, I., Santonja, C., Alonso-Riaño, M., Noguera-Morel, L., Hernández-Martín, A., Andina, D., Wiesner, T., Rodríguez-Peralto, J. L., Requena, L., & Torrelo, A. (2020). SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases. The British journal of dermatology, 183(4), 729–737.

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COVID toes symptoms include blisters, rough skin, and sometimes painful bumps on the toes. Discoloration and swelling may also develop on the toes. The symptoms may last for 10 to 14 days or, in some cases even up to months. These symptoms may also appear on the fingers for some.

Symptoms and Signs of COVID Toes

However, it should be noted that symptoms of COVID toes might be similar to chilblains, which occur due to inflammation and long-term exposure to cold air(1 Trusted Source
What are some of the unusual symptoms of COVID-19?

Go to source). Some people also reported the formation of pus under their skin. Initially, the toes may appear red and gradually turns to purple. The symptoms may occur after, during, or before other COVID symptoms(4 Trusted Source
COVID Toes, Rashes: How the Coronavirus can Affect Your Skin

Go to source).

In most case studies, the Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test turned positive for patients reporting skin manifestations. But interestingly, some studies also found that patients with skin lesions had an increase in inflammatory markers like C-Reactive Protein (CRP) and procalcitonin (PCT). These inflammatory markers may lead to microvascular damage and affect the coagulation system resulting in inflammation and thrombosis(5 Trusted Source
Ozbey, R., & Algan, M. F. (2022). Acro-ischemic lesions in COVID-19 patients: A case series. Journal of cosmetic dermatology, 10.1111/jocd.14893. Advance online publication.

Go to source). Antibody testing conducted at least a week after the onset of symptoms is also advisable(7 Trusted Source
Zaladonis, A., Huang, S., & Hsu, S. (2020). COVID toes or pernio?. Clinics in dermatology, 38(6), 764–767

Go to source). Other factors to be considered in the diagnosis of COVID toes are exposure to cold temperatures during recent times and a history of autoimmune diseases.

Most skin lesions associated with COVID-19 infection do not require treatment. Studies have reported that the symptoms may fade in 7 to 10 days and may resolve completely in 3 to 5 weeks. The most common treatment to alleviate the symptoms includes oral analgesia and antihistamines.

Topical treatment may include heparin, nitroglycerin, and corticosteroids. COVID toes treatment for reducing itchiness and pain may include applying hydrocortisone cream in the affected areas(4 Trusted Source
COVID Toes, Rashes: How the Coronavirus can Affect Your Skin

Go to source, 8 Trusted Source
Dowdle, T., Brown, T., Peterson, J., Banafshay, K., Nguyen, J., & Sturgeon, A. (2021). COVID toes: a unique cutaneous indicator of COVID-19. The Southwest Respiratory and Critical Care Chronicles, 9(39), 15-21.

Go to source).

Treatment for COVID Toes

More studies are needed to gain a complete understanding of COVID toes. However, early detection of skin lesions related to the COVID-19 virus in asymptomatic individuals will prevent its spread to uninfected individuals. Following the treatment protocols advised for COVID-19 infection like isolation and contact tracing will play essential health implications in preventing the spread of infection(9 Trusted Source
Koschitzky, M., Oyola, R. R., Lee-Wong, M., Abittan, B., & Silverberg, N. (2021). Pediatric COVID toes and fingers. Clinics in dermatology, 39(1), 84–91.

Go to source).

Conclusion

Awareness and knowledge about COVID toes among the healthcare community and the public is important and may aid in early diagnosis, the establishment of the right treatment, and prevention of the spread of the virus(8 Trusted Source
Dowdle, T., Brown, T., Peterson, J., Banafshay, K., Nguyen, J., & Sturgeon, A. (2021). COVID toes: a unique cutaneous indicator of COVID-19. The Southwest Respiratory and Critical Care Chronicles, 9(39), 15-21.

Go to source).

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