Skin Changes with Covid 

I decided I needed more information to discuss this with any semblance of knowledge. This posting is an opinion piece, with some validated resources for your review as well. 

Initial Thoughts 

Before I read this article, Cutaneous signs in COVID-19: A review, I thought it was funny in an ironic way, that the authors of this article are all associated with dermatology. The Covid-19 disease process is not a “surface organ” problem – it is an immune response and hematological problem involving inflammation and coagulation challenges, and therefore the resulting skin changes that come with compromised circulation. The coronavirus causes swelling of endothelial cells. The swelling of the endothelial cells has a huge impact on circulation, as every vessel in the human body is lined with these cells. "Endothelial cells form a single cell layer that lines all blood vessels and regulates exchanges between the bloodstream and the surrounding tissues" (Alberts, et al., para. 15). 

Insults to the integumentary system that originate from circulatory deficiencies, are not typically – well, not ever – a dermatology concern, rather these insults call for the interventions by a wound care, vascular, or general surgeon or medical provider that specializes in wound care, vascular diseases, or infectious diseases. The exanthems that occur with Covid-19 would be more of a petechial presentation rather than a confluent, a sporadic, or a satellited, pinpoint, macular rash.   

According to Starkman (2022), when writing about the ‘Covid toe” skin condition, “These skin changes have shown up in people who’ve tested negative for COVID” (para. 5).  Additionally, symptoms just like those found in “Covid toes” have actually been around for quite some time, referred to as chilblains. Chilblains present as itchy red patches on the toes (sometimes fingers too), as a result of cold temperatures (NHS 24, 2020). Additional risk factors for chilblains include: poor circulation, poor diet or low body weight, exposure to cold, Lupus, and Raynaud's phenomenon (NHS 24, 2020).

Rochman (2021) quoted the lead author of a study as saying, “Like other dermatologists, we began to see an increase in patients with chilblains during the pandemic” (para. 3).  

My Experiences with Covid Skin Issues 

I have only provided care for two patients with “Covid toes” as I stopped working in acute inpatient care in March of 2021. The skin changes were like any of the pictures you will find when you “Google” Covid toes images. See Image 1 and Image 2 below. 

         

 Image 1 Skin changes seen with Covid-19 (Rabin, 2020)  

  

   Image 2 Skin changes with Covid-19 (Rochman, 2021) 

Type of Rash  

There was no rash present for either of my patients. They both had nonblanchable discoloration and the presence of swelling and intermittent pain on areas of the toes of both feet that did not feel "itchy" until 12-24 hours after initial onset. Both described the pain as a burning or stinging sensation, which occurs in chilblains (NHS 24, 2020). After reviewing several different publications, all symptoms are present for some, and for others, only the discoloration is present. Some will have other symptoms including blisters and raised, painful red bumps (Starkman, 2022). The American Academy of Dermatology (AAD) (n.d.-a) reports, “If you have swollen, discolored toes or fingers, you may have chilblains instead of COVID toes” (para. 16).  At my recommendation, both of these patients were treated with a moderate strength topical corticosteroid (Triamcinolone 0.1%) to reduce the itching and swelling, and the symptoms resolved within 72 hours of onset.

Manifestation Timeline 

In children, the “Covid toes” may appear in the fingers actually and may be the only sign of a Covid infection (AAD, n.d.-b). The two patients I had were in the late stage or over the virus, and were ready for discharge soon after the condition appeared. For many, according to Noakes & Majoe (2020), the toe issues occurred post-Covid infection. Discolored “Covid toes” are reported to typically occur in children, teens, and young adults, as the only indication that they may have been infected with the SARS-CoV2 virus (Starkman, 2022). Other sources suggest this odd set of symptoms occurs in the early stages of the virus as well as in the late or post stages of acute viral infection (Ketchum, 2021). 

Severity of Associated Illness 

Both patients had been in the ICU, but that is where all of the Covid patients went, in our hospital. One of my patients had been intubated for a portion of his hospitalization and the other had mask and/or CPAP oxygen only.  

Cutaneous Signs as Indicators of the Disease 

As stated previously, some publications indicated that this may be the only sign in children, teens, and young adults. I do not think that this discoloration is an appropriate indicator of the Covid-19 virus or severity.  

Conclusion 

Ultimately, I have not seen any conclusive data that supports "Covid toes” or cutaneous rashes as a Covid-19 disease indicator or indicator of Covid infection severity. As I stated previously, Covid is a disease process that affects the immune system and has hemotological implications. The swelling of the endothelial cells in response to the SARS-CoV2 virus, has a huge impact on circulation, because every vessel in the human body is lined with endothelial cells. As a Certified Wound, Ostomy, Continence nurse, I see this as acute tissue changes resulting from the impairment in the circulatory system, which can happen in those that were infected with SARS-CoV2, but can also occur in other inflammatory, circulatory conditions. 

In my opinion, this is in no way an indicator of Covid severity, nor a finding that would prognosticate a Covid-19 infection.  

References  

Alberts, B., Johnson, A., Lewis, J., Raff, M., Roberts, K., & Walter, P. (2002). Blood Vessels and Endothelial CellsVersion (4th edition). In Molecular biology of the cell: A problems approach (4th ed.). Garland Science. Retrieved May 19, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK26848/Links to an external site. 

American Academy of Dermatology. (n.d.-a). Covid toes, rashes: How The coronavirus can affect your skin. Coronavirus Resource Center. https://www.aad.org/public/diseases/coronavirus/covid-toesLinks to an external site.  

American Academy of Dermatology. (n.d.-b). Rash: Sign of coronavirus in kids. https://www.aad.org/public/diseases/coronavirus/coronavirus-rash-signs-kidsLinks to an external site.  

Ketchum, D. (2021, March 39). Are covid toes and hands an early sign of covid-19? https://www.getbrio.com/post/purple-covid-toes-and-handsLinks to an external site.  

NHS 24. (2022, November 25). Chilblains. https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/chilblainsLinks to an external site.  

Noakes, A., & Majoe, S. (2020, June 24). Understanding the role that “covid toe” has in recognizing the potential extent of covid-19 infections: A case study. Pathogens and global health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480604/Links to an external site.  

Rabin, R. C. (2020, May 1). What is “covid toe”? maybe a strange sign of coronavirus infection. The New York Times. https://www.nytimes.com/2020/05/01/health/coronavirus-covid-toe.htmlLinks to an external site.  

Rochman, S. (2021, June 23). “Covid toes” were likely not caused by covid-19, in most cases. NCAL Research Spotlight. https://spotlight.kaiserpermanente.org/covid-toes-not-caused-by-covid/Links to an external site.  

Starkman, E. (2022, December 24). Covid toes: What you should know. https://www.webmd.com/covid/what-are-covid-toesLinks to an external site. 

Wollina, U., Karadağ, A. S., Rowland-Payne, C., Chiriac, A., & Lotti, T. (2020, September). Cutaneous signs in COVID-19 patients: A Review. Dermatologic therapy. Retrieved May 6, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273098/Links to an external site.