More than COVID toes: skin manifestations of coronavirus may be wide and varied

The skin manifestations associated with COVID-19 are more than just “covid toes.”

In fact doctors with the American Academy of Dermatology are noticing a wide variety of rashes that may be associated with the virus that causes COVID-19, enough that the organization has started a registry for health care professionals to submit cases.

“We think they’re associated with the pandemic and virus right now because we don’t see much of them otherwise,” Dr. Amy Paller said of these wide variety of rashes. “We don’t know if it represents some other virus, some other exposure or if it’s really a manifestation of the virus.”

Paller is the chair of the department of dermatology and the director of the Skin Biology and Diseases Resource-Based Center at Northwestern University Feinberg School of Medicine.

"Covid toes,” a term now familiar to many people, are red and purple lesions also known as chilblains or pernio (painful inflammation of blood vessels) and are typically seen after cold exposure and not usually this time of year, Paller said.

“They’re particularly being seen in adults or teenagers who have relatively mild or the most common signs we associate with covid,” Paller said.

Sometimes the red-purple discoloration in the tops of the toes or the bottoms of fingers persists for a few weeks and sometimes patients have a little pus under the skin. But doctors are no seeing consistent positive tests for the virus in patients with these rashes or even positive antibody tests, Paller said

“Nevertheless, we think there’s a real phenomenon going on here and we’re trying to figure out if and how it relates to the covid infection,” Paller said. “We just don’t know.”

The other rash being seen in children is a multisystem inflammatory syndrome. It’s been described as Kawasaki syndrome, toxic shock syndrome, the rash associated with measles and even scarlet fever, Dr. Stephen P Stone, professor, division of dermatology, SIU School of Medicine, pictured above, said.

Scarlet fever is a bacterial infection caused by group A streptococcus or group A strep, according to the Center for Disease Control (CDC).

But more rashes are being reported, too, Stone said. As the covid virus spread through Italy, reports mentioned how some patients – as many as 1 in 5, had some type of rash, he said.

“Generally it was described as a patchy rash,” Stone said. “But some of the patients were describing rashes that looked like hives. And there was at least one patient out of Italy that had little blisters on the trunk like chicken pox. Which raises the questions? Was this a coincidence? Was it related to the fever?”

Stone said other rashes resemble petechiae (round pinpoint spots caused by bleeding), which “is not your everyday rash." And two U.S. dermatologists have reported a rash that looked like patchy eczema, he added.

At this point Stone doesn’t feel the rashes are coincidental. But they’re so non-specific that most dermatologists, if they’re only seeing the rash, wouldn’t automatically think “covid,” especially if the person has no other signs of illness, he said.

"If you’re taking medication and develop a rash, the first thing I would think of is a drug reaction,” Stone said. “But if you’re having cough and fever and body aches – flu-like symptoms – and you develop a rash, then yes, I would think about that possibility.”

Many other viruses do cause rashes. These include chicken pox, fifth disease, measles, mononucleosis and roseola.

Not every rash that may appear is related to covid. And some non-covid rashes also need medical treatment, such as a petechial rash, he said.

“A mild rash in a patient who’s feeling well could be the prodrome of a viral infection,” Stone said. “But more often than not, its’ an allergic reaction that fades away before the person has a chance to make an appointment with a doctor.”

This is where telemedicine can be extremely useful.

“If you can take a decent photo with your mobile phone, it’s amazing how helpful that can be for your doctor,” Stone said.

Registry for heatlh professionals

The American Academy of Dermatologists is encouraging health professionals of any specialty or country to register any cases they see with the Dermatology COVID-19 Registry AAD Ad Hoc Task Force on COVID-19

Patients should not enter their own cases They may share the link with their health care professionals.

To register and for more information, visit aad.org/covidregistry