• Ivan Bristow

COVID Toes - November 2020 Update

This is an update circulated to College of Podiatry Members on 2nd November 2020

With the global pandemic continuing into November, data from John Hopkins University suggests nearly 30 million people globally have been infected with over 1 million deaths (Data as of 31/10/2020: https://coronavirus.jhu.edu/map.html). Research into the disease continues to be published at a significant rate. A range of skin presentations have been observed and reported [1-4]. Common lesions patterns include:

· Morbilliform (measles-like) rash

· Urticaria

· Macular erythema

· Vesicular (blistering, chickenpox-like) eruption

· Papulosquamous presentation

· Retiform (net-like) purpura

· Chilblain-like lesions

Published data from the International Registry of COVID-19 Associated Dermatologic Manifestations has been collated from 31 countries to date. Analysis shows that lesions have been reported across all continents, in a full range of skin types (including white, Asian, Black African / African American and Latin / Hispanic patients) [5].

Literature pertaining to the phenomenon of chilblain-like lesions (often labelled COVID toes) has been reviewed and circulated by the College of Podiatry to members in its regular e-bulletins. This week, media interest in COVID toes was reignited by a presentation made at the European Academy of Dermatology in Switzerland. Dr Esther Freeman who leads the International COVID Dermatology Register presented data to dermatologists which included collected data on the phenomenon. They reported that the chilblain lesions, in line with previous research, lasted around 12 days on average however, they cited 6 patients who continued with the purple lesions on their toes lasting over 60 days in patients who tested positive for the disease with two of these showing skin lesions at 130 days after diagnostic confirmation. They conclude that such a prolonged presence of the lesions may represent a symptom of the condition termed “Long COVID” where symptoms of the disease may manifest for many weeks after the initial infection but further research is required to fully explain this.

Data published so far on COVID-19 and the skin has been analysed in a paper by Danaheshgaran et al. [6]. In their work, thirty-four papers describing nearly 1000 patients with various skin symptoms were included and demonstrated that chilblains were the most reported dermatological condition, representing 40% of all dermatological conditions in COVID patients. The average age of these patients was 23.2 years old. Lesions generally developed after the onset of the signature symptoms (persistent cough, temperature etc.,) which concurs with earlier observations that such lesions are generally a later manifestation of the disease. Although viral particles have been recovered from chilblain-like lesion biopsies [7, 8], the exact mechanism by which they develop is still requires further investigation.


1. Manalo IF, Smith MK, Cheeley J, Jacobs R: A Dermatologic Manifestation of COVID-19: Transient Livedo Reticularis. J Am Acad Dermatol 2020.

2. Marzano AV, Genovese G, Fabbrocini G, Pigatto P, Monfrecola G, Piraccini BM, Veraldi S, Rubegni P, Cusini M, Caputo V et al: Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients. J Am Acad Dermatol 2020:early view.

3. Recalcati S: Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol 2020.

4. Gianotti R, Veraldi S, Recalcati S, Cusini M, Ghislanzoni M, Boggio F, Fox LP: Cutaneous Clinico-Pathological Findings in three COVID-19-Positive Patients Observed in the Metropolitan Area of Milan, Italy. Acta Derm Venereol 2020.

5. Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Desai SR, Harp J, Takeshita J, French LE, Lim HW et al: The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries. J Am Acad Dermatol 2020.

6. Daneshgaran G, Dubin DP, Gould DJ: Cutaneous Manifestations of COVID-19: An Evidence-Based Review. Am J Clin Dermatol 2020, 21(5):627-639.

7. 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

8. Santonja C, Heras F, Núñez L, Requena L: COVID-19 chilblain-like lesion: immunohistochemical demonstration of SARS-CoV-2 spike protein in blood vessel endothelium and sweat gland epithelium in a polymerase chain reaction-negative patient. Br J Dermatol 2020