Covid-19 the skin and toes

‘Covid toe’ is part of the corona virus syndrome. As we are starting to see different types of skin problems, all clinicians treating patients will be pushed to make a diagnosis. Readers provide information all the time and this recent BBC news information brings this article up to speed. Back in June 2020 podiatrist Debbie Delves described her first experience with one such patient. Here is Debbie’s case report. This report was one of the first officially recorded by a podiatrist in the UK. Of course the progress of Covid, Delta and now Omicron variants make daily news and have changed the landscape of healthcare delivery. Podiatrists are a first line practitioner in the field with majority working in the independent field. They offer more than just foot health awareness.

Case Report: Covid toe suspected?

Covid toe the skin and toes

I had just started advertising video consultations and a young patient around 31 years of age contacted me because he had a rash on his foot and he wanted my opinion. We booked for the Tuesday after Easter and he had sent ahead some photos. I didn’t want to wait until Tuesday (the day of the scheduled online consultation) as his partner might be going back to work and this might have had wider implications. However, he had locked down already because he was working from home. Almost 4 weeks ago these cases had been unknown. I decided to phoned him up and ask if we could do the consultation on the Monday although I didn’t want to alarm him so I kept it low-key. Anyway, we met as planned and I went through his general medical history. As I glanced at the pictures they seemed strange and looked like really bad chilblains, but for April that didn’t fit the usual clinical picture. It just so happened before this the subject of Covid Toe hit one of the podiatry groups on Facebook. As I looked at my patient’s pictures I thought, ‘oh my God this is so similar!’

He was fit and healthy and the rash had just appeared a couple of weeks ago. I asked if he had had any symptoms and he declared that he had had a bit of a chesty problem which he put down to hay fever, but he had an awful headache. This happened just before the rash had appeared and that was it. I told him what I thought it was. I said you’re going to think this bizarre, he said ‘I’ve never heard of this’. I told him that he needed to phone NHS111 for advice because I don’t know what the advice is at the present time? Even our profession had not convened an opinion. I told him they may think I’m a nutter because nobody has ever heard of it. So he went off and Googled Covid Toe and found that papers existed and he believed me. As a podiatrist I have a wealth of knowledge about foot health but this was something that no one had ever heard of and you find yourself trying to tell a patient that you feel they should self isolate now in case they get any symptoms and the implications of cross infection if they were going to work, and what advice 111 would give. This was a really hard and a difficult conversation to initiate, that you’ve got no other symptoms other than weird rash on your toe!

The weird rash is still there

In consultation with a podiatric colleague who specialises in dermatology he advised that the rash could remain for quite a few weeks. I’ve naturally been updating my patient. These rashes exist around the distal interphalangeal joint or knuckle joint at the tip end of the toe as well as surrounding skin around the nail. The condition does just look like chilblains.

Italy March 8th

The questions over these red areas (lesions) are noticed at the end of the toe. A case is reported of a 13-year-old boy on March 8^th noticed by a paediatrician. The article is headed; Acute acro-ischemia in the child at the time of Covid-19 (Dermatologia Pediatrica, Bari. Mazotta, F, Troccoli 2020). The information came from Italy where outbreaks in Lombardy, Veneto, Emilia and Romagna had been prolific with high death rates in both medical staff and patients. It turns out that toe lesions alone would not be the only skin change seen and the press soon were to report these additional changes seen in patients.

Daily Telegraph

On 28^th April (2020) the Daily Telegraph headed up an alert on page 8; UK ALERT AS NEW SYNDROME PUTS CHILDREN IN INTENSIVE CARE. Pictures of lesions on a toe and sole of the foot were reproduced. By 1^st May, the Daily Telegraph reported with more headlines on its allied health page 8. SKIN CONDITIONS LINKED TO INFECTION, RESEARCH SHOWS. Spain’s Dermatologists has also reported ‘how the disease might manifest in skin symptoms’. In the UK the paper reported ‘that authors of the study in the British Journal of Dermatology said that in some cases it was hard to tell if skin conditions were caused directly by coronavirus or indicated complications’.

Royal College of Podiatry

Various groups have been putting together collective advice which includes the College of Podiatry. The link between the skin and acral lesions and COVID 19 has not been proven definitively. Clinicians were advised to use their own clinical judgement at this stage. The College believed that there was no current recommendation for patients on the basis of these skin lesions without positive symptoms. Organisations continue to collect evidence and data. The concerns for foot lesions has expanded and British podiatrists have started to work with the USA and Australia to further understand the implications for their patients.

In the USA

Rami Basatneh and Tracey Vlahovic in the USA wrote to the editor of the Journal of American Podiatric Medical Association addressing the question of dermatologic manifestation of SARS-Cov-2 and infection in the lower limb (DOI:10.7547/20-074). Their concern was to pull together facts about the virus and understand the implications;

In the meantime there are several efforts to keep an eye on research as this space continues to grow. However until the community can assess the fruits of those efforts, any definitive statements regarding correlation between the novel coronavirus should be reserved until more evidence is analysed.

Bristow’s Foot Expert site is the top podiatric site presently available not just to podiatrists but in keeping with the spirit of open information access. For ConsultingFootPain, a site that believes in sharing quality and reliable information all should be able to share vital information for public foot health awareness. Download his latest article below.

Dr Bristow writes on his website

Thanks for reading Covid-19 skin and toes edited by David R Tollafield

Original 19 June 2020 modified December 2021

Covid-19 the skin and toes