Is It Covid Toes or Chilblains?

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Dry, red, itchy skin on the toes and fingers? Known as chilblains or pernio, this condition can affect people who have been exposed to prolonged cold, especially in damp climates.

Chilblain is a bit of an uncommon problem, but it can affect anyone who has been exposed to the severe cold outdoors or who lives or works in poorly heated conditions. However, chilblains-like presentations have been popping up with more regularity over the past few months. One San Francisco-based dermatologist reported to the New York Times in May 2020 that, whereas she used to see four or five patients with chilblains per year, now she is seeing dozens.

Many health experts have begun to suspect that COVID-19, not chilblains, is to blame for these new cases. The American Academy of Dermatology Association (AAD) published a resource detailing unusual findings in the past year related to alleged “COVID toes”. The presentation is very similar to chilblains, but patients have no recent history of cold exposure. Cases range from mildly discomforting to painful, at the point of disrupting normal activities.

Anyone concerned about their symptoms and the possible relationship to COVID-19 can address their condition with the assistance of a licensed podiatrist near them. They can also review the information below to better understand their condition and whether or not it is related to a possible COVID-19 infection.

What Is Chilblains, and What Causes It?

The United Kingdom’s National Health Service (NHS) defines chilblains as “small, itchy, red patches that can appear after you have been in the cold.” The NHS also assures that, “chilblains usually go away on their own in 2 to 3 weeks.”

The presentation may be consistent with a rash, or it may look similar to reddish windburn on the cheeks. People with darker skin and people of color may see shades of purple in the rash rather than redness. Some people suffering from chilblains may even see significant swelling or deep discoloration. In severe or poorly managed cases, the affected skin may blister or ulcerate. Pus may also emerge from underneath the outer skin layer.

A common complication of chilblains arises when the patient continues to expose themselves to cold without proper precaution. They may have footwear or socks that retain moisture and fail to properly insulate. Many patients also can pick at the affected areas, rub them, or get overzealous in warming the areas back up. This is likely to worsen the tissue damage that caused chilblains in the first place.

The mechanism by which patients get chilblains is not yet fully understood. Harvard Health Publishing documents that “the cause appears to be damage to tiny blood vessels (capillaries) in the skin. When skin is exposed to cold, the capillaries constrict, and in susceptible people, some may become damaged. When the skin is rewarmed too quickly, they leak blood into the surrounding tissue, causing inflammation. Susceptibility may be increased by poor circulation, anemia, hormonal changes, connective tissue problems, and certain bone marrow disorders.”

Individuals with diabetes may also be more susceptible to chilblains.

What Is “COVID toes”?

“COVID toes” has emerged as a way to describe patient cases involving a reaction very similar to chilblains but without an obvious history of exposure to cold. 

Absent the history of cold exposure, diagnostic professionals have theorized that itchy hands and feet could be an unusual reaction to COVID-19 infection. As detailed by the AAD, many patients who have tested positive for COVID-19 have developed hives or rashes. In some “COVID toes” cases, the patient even has measles-like bumps on the skin of their toes and feet.

A review of patient studies published in January 2021 in the medical journal Clinics in Dermatology noted that these cases seem to emerge with particular frequency in teens and children. As affirmed by the CDC, young children and teens are less likely to have severe COVID-19 symptoms. They may, instead, present symptoms that are more subtle, such as a mild cough. They may also have zero symptoms, albeit while still spreading the virus to others. Because COVID-19 is less likely to be suspected in mild respiratory cases, the appearance of rashes on these young individuals is particularly unexpected.

However, individuals of all ages have presented with “COVID toes”, including a documented case of a 48-year-old woman with a mild rash that was first noticed on her cat’s ears.

Why Would COVID-19 Cause Chilblains-Type Rashes?

The true answer is that no one knows for sure yet. COVID-19 is a completely novel disease, and its effects will undoubtedly be researched and theorized over for many decades to come.

One consistent thread, though, is that severe COVID-19 cases seem to be related to the body’s reaction to the disease rather than damage caused by the infection itself — i.e. a severe immune system overreaction caused by “autoantibodies.” Some COVID-19 patients develop severe lung inflammation and lung tissue lesions. Others see complications related to clotting or abnormal functioning in organs far away from the respiratory system. The theory is that what these cases have in common is that the COVID-19 infection has caused the body’s immune system to “go rogue”, sometimes attacking perfectly healthy tissues.

Since hives can emerge as the body’s natural histamine response to an allergen, a similar reaction might be happening in patients with “COVID toes” rashes on their hands or feet. Chilblain is a condition likely caused by damage to small capillaries, so rapid inflammation or even apoptosis (the body killing off its own cells) may be at work in patients with “COVID toes”.

Should I Be Worried About COVID If I Get a Chilblains-Type Rash?

Many healthcare professionals have been quick to point out that the relationship between COVID-19 and chilblains-type rashes is poorly understood, and the connection has not yet been firmly established. 

Further, people should be more focused on watching for other symptoms more likely to indicate a COVID-19 infection. Know that difficulty breathing, persistent cough, fever, and other symptoms are more likely to be connected with COVID-19 infection than rashes on the feet and hands. 

“These symptoms seem to be more common in COVID-19 compared with all other viral infections,” Pulmonologist Dr. Humberto Choi explained to the Cleveland Clinic. “But at this time, they haven’t affected a majority of people. So, the symptoms that people should be looking for are really a fever, cough, and muscle aches that you can get when you have a viral infection. Those are the most common symptoms — and those are the things that people should be keeping on their radar.”

This is not to say that anyone concerned about COVID toes should feel discouraged from taking an antibody (PCR) test. Individuals should also continue to take COVID-19 precautions recommended by the CDC, including social distancing, wearing a mask, avoiding large gatherings, and scheduling an immunization if they have not done so already.

So, while a rash on toes and hands is not as much of a concern as fever, chest pain, severe cough, or other symptoms, individuals can still take precautions and get themselves tested in order to alleviate their concerns about rashes on the hands and feet.

Treating Chilblains and COVID Toes

The good news is that, in nearly all cases, both chilblains and suspected “COVID toes” can resolve themselves in just a few weeks. Sufferers are recommended to keep the affected areas clean, dry, and reasonably warm. Hydrocortisone creme and a mild, doctor-recommended lotion can help to soothe the itching and discomfort.

Avoid excessively massaging, rubbing, scratching, or picking at the feet. If the condition persists past 2 weeks, appears to be getting worse, or develops into broken skin or the appearance of pus, have it evaluated by a podiatrist as soon as possible.

If you have any questions about a foot rash or other conditions or would like an evaluation, you can call us at (801) 396-9743 or schedule an appointment with a podiatrist in Salt Lake City at a location near you.