Abstract: The novel Coronavirus Disease 2019 (COVID-19) presents with a wide range of symptoms. These may include fever, pneumonia, headaches, sore throat, diarrhea, strokes, liver and kidney damage, loss of taste. Yet, the most bizarre documented presenting symptoms has been “COVID toes.” Overall, the fifteen studies conducted found that patients with dermatologic symptoms often displayed chilblain-like skin lesions, pernio-like, urticarial, macular erythema, vesicular, papulosquamous, and retiform purpura. Patients presenting with COVID toes, regardless of confirmatory COVID-19 laboratory results, demonstrated epidermal necrotic keratinocytes, dermal edema, perivascular and perieccrine sweat gland lymphocytic (CD3/4+) inflammation, vascular changes with endothelialitis, microthrombosis, fibrin deposition, and immune reactant deposits on vessels. Histopathological immunohistochemical and direct immunofluorescence from biopsy showed IgM deposits in most of the cases. Patient symptoms varied in severity from milder pernio-like lesions to progressive retiform purpura. These findings could aid in triaging patients with COVID toes. This may prevent the progression to the known neurologic and destabilizing thrombotic events seen in many COVID-19. In patients with lesions, early identification and intervention with antivirals, antiplatelets, and anticoagulants to prevent hypoxia and reperfusion injuries may be avoided. Dermatological features are often overlooked; distinct clinical signs of COVID-19 and further awareness and research are indicated.

References and Resources

1. Askin O, Altunkalem RN, Altinisik DD, Uzuncakmak TK, Tursen U, Kutlubay Z. Cutaneous manifestations in hospitalized patients diagnosed as COVID-19 [published online ahead of print, 2020 Jun 24]. Dermatol Ther. 2020;10.1111/dth.13896. doi:10.1111/dth.13896
2. Cantador E, Núñez A, Sobrino P, et al. Incidence and consequences of systemic arterial thrombotic events in COVID-19 patients [published online ahead of print, 2020 Jun 9]. J Thromb Thrombolysis. 2020;1-5. doi:10.1007/s11239-020-02176-7
3. Colmenero I, Santonja C, Alonso-Riaño M, et al. SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultraestructural study of 7 paediatric cases [published online ahead of print, 2020 Jun 20]. Br J Dermatol. 2020;10.1111/bjd.19327. doi:10.1111/bjd.19327
4. Cordoro KM, Reynolds SD, Wattier R, McCalmont TH. Clustered cases of acral perniosis: Clinical features, histopathology, and relationship to COVID-19. Pediatr Dermatol. 2020;37(3):419-423. doi:10.1111/pde.14227
5. Criado PR, Abdalla BMZ, de Assis IC, van Blarcum de Graaff Mello C, Caputo GC, Vieira IC. Are the cutaneous manifestations during or due to SARS-CoV-2 infection/COVID-19 frequent or not? Revision of possiblepathophysiologic mechanisms. Inflamm Res. 2020;69(8):745-756. doi:10.1007/s00011-020-01370-w
6. Damsky W, Peterson D, King B. When interferon tiptoes through COVID-19: Pernio-like lesions and their prognostic implications during SARS-CoV-2 infection [published online ahead of print, 2020 Jun 18]. J Am Acad Dermatol. 2020;S0190-9622(20)31150-6. doi:10.1016/j.jaad.2020.06.052
7. El Hachem M, Diociaiuti A, Concato C, et al. A clinical, histopathological and laboratory study of 19 consecutive Italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with COVID-19 infection [published online ahead of print, 2020 May 31]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16682. doi:10.1111/jdv.16682
8. Freeman EE, McMahon DE, Lipoff JB, et al. The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries [published online ahead of print, 2020 Jul 2]. J Am Acad Dermatol. 2020;S0190-9622(20)32126-5. doi:10.1016/j.jaad.2020.06.1016
9. Garg S, Garg M, Prabhakar N, Malhotra P, Agarwal R. Unraveling the mystery of Covid-19 cytokine storm: From skin to organ systems [published online ahead of print, 2020 Jun 19]. Dermatol Ther. 2020;e13859. doi:10.1111/dth.13859
10. Hernandez C, Bruckner AL. Focus on “COVID Toes”. JAMA Dermatol. Published online June 25, 2020. doi:10.1001/jamadermatol.2020.2062
11. Kanitakis J, Lesort C, Danset M, Jullien D. CHILBLAIN-LIKE ACRAL LESIONS DURING THE COVID-19 PANDEMIC ("COVID TOES"): HISTOLOGIC, IMMUNOFLUORESCENCE AND IMMUNOHISTOCHEMICAL STUDY OF 17 CASES [published online ahead of print, 2020 Jun 2]. J Am Acad Dermatol. 2020;S0190-9622(20)31022-7. doi:10.1016/j.jaad.2020.05.145
12. Landa N, Mendieta-Eckert M, Fonda-Pascual P, Aguirre T. Chilblain-like lesions on feet and hands during the COVID-19 Pandemic. Int J Dermatol. 2020;59(6):739-743. doi:10.1111/ijd.14937
13. Mayor-Ibarguren A, Feito-Rodriguez M, Quintana Castanedo L, Ruiz-Bravo E, Montero Vega D, Herranz-Pinto P. Cutaneous small vessel vasculitis secondary to COVID-19 infection: a case report [published online ahead of print, 2020 May 22]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16670. doi:10.1111/jdv.16670
14. Novara E, Molinaro E, Benedetti I, Bonometti R, Lauritano EC, Boverio R. Severe acute dried gangrene in COVID- 19 infection: a case report. Eur Rev Med Pharmacol Sci. 2020;24(10):5769-5771. doi:10.26355/eurrev_202005_21369
15. Zhao Q, Fang X, Pang Z, Zhang B, Liu H, Zhang F. COVID-19 and cutaneous manifestations: A systematic review [published online ahead of print, 2020 Jun 28]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16778. doi:10.1111/jdv.16778