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What Is ‘Covid Toe’? Maybe a Strange Sign of Coronavirus Infection

Dermatologists say the lesions should prompt testing for the virus, even though many patients have no other symptoms.


Chilblains, the painful red inflammations that are normally associated with exposure to cold air. A similar condition has been showing up in Covid-19 patients. (Science Source)

By Roni Caryn Rabin
May 1, 2020

Before the coronavirus outbreak, Dr. Lindy Fox, a dermatologist in San Francisco, used to see four or five patients a year with chilblains — painful red or purple lesions that typically emerge on fingers or toes in the winter.

Over the past few weeks, she has seen dozens.

“All of a sudden, we are inundated with toes,” said Dr. Fox, who practices at the University of California, San Francisco. “I’ve got clinics filled with people coming in with new toe lesions. And it’s not people who had chilblains before — they’ve never had anything like this.”

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Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing. (Covid-19 is the name of the illness caused by the coronavirus.)

Several medical papers from Spain, Belgium, and Italy described a surge in complaints about painful lesions on patients’ toes, Achilles' heels and soles of the feet; whether the patients were infected was not always clear, because they were otherwise healthy and testing was limited.

Most cases have been reported in children, teens, and young adults, and some experts say they may reflect a healthy immune response to the virus.

“The most important message to the public is not to panic — most of the patients we are seeing with these lesions are doing extremely well,” Dr. Freeman said.

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Patients who get painful lesions are often alarmed. They appear most frequently on the toes, often affecting several toes on one or both feet, and the sores can be extremely painful, causing a burning or itching sensation.

At first, the toes look swollen and take on a reddish tint; sometimes a part of the toe is swollen, and individual lesions or bumps can be seen. Over time, the lesions become purple in color.

Hannah Spitzer, 20, a sophomore at Lafayette College who is finishing the academic year remotely at her home in Westchester County, has lesions on all 10 of her toes, so uncomfortable — painful during the day, and itchy at night — that she can’t put anything on her feet, not even socks.

Walking is difficult, and she has trouble sleeping. “At first I thought it was my shoes, but it got worse and worse,” Ms. Spitzer said. “Most of my toes are red, swollen, almost shiny. It looks like frostbite.”

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But she also dismissed that idea as highly unlikely. “I don’t think that’s it — I think it’s a mild inflammatory process manifesting in this way,” Dr. Paller said. “It’s a real phenomenon. We don’t really understand it at all.”

Ms. Spitzer had a test shortly after developing the lesions, and the result was negative, but she is convinced the toe lesions are a delayed response to an earlier infection that was so mild she barely noticed it.

“I’ve never had anything like this,” she said. “It’s completely new.”

A recent paper by doctors in Spain, published in the International Journal of Dermatology, described six cases of patients with toe lesions and included pictures of the chilblain-like bumps that patients had emailed to their physicians.

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Patients with viral infections often get a pink bumpy rash called morbilliform, or hives, Dr. Fox said, but added that the toe lesions were “unexpected.”

The toe cases make up half of all reports filed by skin doctors around the world to a new international registry started by the American Academy of Dermatology, which is tracking the complications.

No one knows exactly why the new coronavirus might cause chilblain-like lesions. One hypothesis is that they are caused by inflammation, a prominent feature of Covid-19. Inflammation also causes one of the most serious syndromes associated with the coronavirus, acute respiratory distress syndrome.

Other hypotheses are that the lesions are caused by inflammation in the walls of blood vessels, or by small micro clots in the blood. (Clotting has been another feature of the disease.)

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