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May 11, 2020

'COVID toes' an unusual sign of the coronavirus – and an itchy one

Lesions often appear on people who were otherwise asymptomatic

Illness COVID-19
COVID toes Brina Blum/Unsplash

'COVID toes' are the latest possible coronavirus symptom being observed by doctors – and an unusual one. Some COVID-19 patients report tender, itchy lesions on their feet, but otherwise display no symptoms of the coronavirus.

Some people with COVID-19 are developing painful lesions on their feet and toes despite experiencing no other symptoms of the coronavirus. 

The lesions are the latest in a growing list of possible symptoms and complications tied to COVID-19. The phenomenon is not well understood, but it appears to generally occur in the early stages of infection.

"This is a manifestation that occurs early on in this disease, meaning you have this first, then you progress," Dr. Ebbing Lautenback, chief of infectious disease at Penn Medicine, told USA Today. "Sometimes this might be your first clue that they have COVID when they don't have any other symptoms."

In some patients, these lesions have disappeared within 10 days and the patients have recovered. Others have later developed additional symptoms, including respiratory problems. Some doctors have reported "COVID toes" in their most critical patients, including those with acute respiratory distress syndrome.

Infectious disease experts suggest that "COVID toes" might be the result of the body's inflammatory response being focused on the foot and toes. The lesions also could be tied to the clotting of blood vessels in these extremities. But there are no clear answers.

Similar lesions also occur in other types of viral infections, particularly viral respiratory infections that lead to ARDS. 

Many of the cases involving so-called "COVID toes" have been in children and young adults. Dr. Robin Gehris, division chief of pediatric dermatology at UPMC Children's Hospital of Pittsburgh has documented about 30 cases of "COVID toes" in children, teens and young adults under 26.

Many of them had symptoms similar to COVID-19 several weeks before their toe lesions appeared. "COVID toes" appeared as red or purple lesions that were tender, itchy or both. 

“Patients with 'COVID toes' seem to be healthy when it presents and we wonder if they could be in the process of mounting an antibody response to the virus with secondary inflammation,” Gehris told the Pittsburgh Post-Gazette.

Because the number of cases associated with COVID-19 is still relatively small, it is not time to panic, said Dr. Humberto Choi, a pulmonologist at the Cleveland Clinic.

"It's important for everyone to know that the most common symptoms for COVID-19 are really respiratory symptoms and symptoms that are similar to those of the flu," Choi said. "For example, a dry cough, heavy fever and feeling tired."

"COVID toes" may just be another way the body can respond to a viral infection, he said.

"It's a different form of manifestation and it is still not very clear what causes it," Choi said. "One pattern of 'COVID toes' that people are reporting is red lesions typically on the soles. It's possible that this is a skin reaction or caused by a small clog or micro clots in the blood vessels in the toes."

Choi has observed similar lesions on patients with sepsis and on people on life support.

He encouraged anyone who develops such lesions to contact their health care provider and get tested for COVID-19 as soon as possible.

The most common symptoms of COVID-19 are fever, shortness of breath and dry cough. The U.S. Centers for Disease Control and Prevention has expanded its list of COVID-19 symptoms to include chills, repeating shaking with chills, muscle pain, headache, sore throat and new loss of taste or smell.

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