COVID toes is the topic of a lecture given by Dr. Maria Del Mar Ruiz Herrera in Spain. One of Dr. Herrera’s PowerPoint slides lists the foot skin manifestations of COVID-19 as a chilblains-like lesion or as a vasculitis-like presentation on fingers and toes that can occur in children, teenagers and adults who have been diagnosed as positive for COVID-19 or are asymptomatic. These individuals can experience hives or no symptoms of these lesions.

Spanish General Council of Official Podiatrist Colleges that stated lesions like those observed in chickenpox, measles or chilblains presented on the toes of young patients in France, Italy, and Spain.  They did not report concrete numbers of patients affected, if the patients were on medication at the time of observation of these skin manifestations or when clinicians noted these lesions (before or after patients were diagnosed as being COVID-19 positive).

International Federation of Podiatrists also discussed a 13-year-old boy in Italy who had pedal purpura that progressed to blistering and necrotic lesions that ultimately resolved. Due to the other symptoms of fever, muscle pain, headache and intense itching of the lesions, a physician diagnosed the patient as having a spider bite. Of note, the patient’s mother and sister had respiratory symptoms a week before the patient’s skin lesions appeared.

In Italy, health-care practitioners confirmed dozens of reports of acrocyanotic lesions in asymptomatic COVID-19-positive children and adolescents who were generally in good health prior to the skin rash onset. These patients tend to have lesions on their feet although the hands may be affected as well. For the foot lesions in these patients, they affect the toes and bottom part more commonly, but may not affect all the toes. According to these reports from Italy, the lesions may appear red to blue, may become bullous or develop “blackish crusts,” be painful and evolve over two weeks, but ultimately resolve on their own.

To assess for this condition, here are some thoughts:

  1. Skin lesions may be primarily on the trunk so check for recently developed a skin rash somewhere else on the body.
  2. Other causes of these can include vasculitis due to sepsis/infection, drug reaction or an underlying connective tissue disorder.
  3. Consider symptoms of other members of the household as the child may be asymptomatic for the COVID-19 virus.