COVID-19: Skin Rashes Including COVID Toes Leave Experts Puzzled

Around the world, many cases of skin rashes in COVID-19 patients are emerging. But the rashes are not similar everywhere—some appear as tiny red spots, while others have characteristics of flat or raised lesions; some appear as a hive-like structure, and some look like frostbites. 

The skin rashes have puzzled doctors. It is still unclear whether these rashes are caused by SARS-CoV-2 or whether they are related to some other factors. Dr. Kanade Shinkai, a professor of dermatology at the University of California and editor-in-chief of JAMA Dermatology journal quoted to have said, “It's unclear whether the skin lesions we see in COVID are actually a direct manifestation of the virus in the skin, or whether they are a "reaction pattern" due to a generally ramped-up immune system.” 

Possibility of the rashes being the manifestation of some co-infections or due to medication or due to complication of the disease can’t be denied. On April 30, Dr. Shinkai and colleagues expressed this uncertainty over the skin rashes in COVID-19 patients in the editorial of JAMA Dermatology. While social media and other platforms have called attention to the rashes, information based on scientific evidence is still needed to answer many questions, like—are the rashes very common among COVID-19 patients or what the rashes mean with respect to the ultimate outcome of the patients?

Skin rashes caused by viral infections are well known. For example, chicken pox, measles etc. do have their hallmark of skin rashes. “But virus-related rashes are more typically seen in children, and that's why it's much more striking to see numerous reports of rashes in adult patients with COVID-19”—said Shinkai. 

It also remains unclear how common these rashes are. In one early study conducted on over 1,000 COVID-19 patients in China, only 0.2% of the patients were reported to have shown rashes. This was published in the New England Journal of Medicine. But a more recent study from Italy, showed that 20% of the 150 COVID-19 patients had skin rashes. This study, conducted by dermatologists was published in the Journal of the European Academy of Dermatology and Venereology on March 26.

There are other reports from Spain and France also about skin rashes in COVID-19 patients. Moreover, another challenge is that some patients may remain asymptomatic, showing no other symptoms of the disease. 

Rash types are also observed to be varied among the patients. For example, a Spanish study published in the British Journal of Dermatology on April 29, reported to have five types of rashes that include the Covid Toe (a frostbite-like rash on the toes), measles-like red spots along with other types of rashes. 

Regarding the timing of the appearance of the rashes, some cases have rashes that precede other typical symptoms like fever, while other cases may have the rashes quite late in the course of infection. 

It is not known whether the virus can be detected on the skin, like some other viruses that cause skin rashes. nor it is known whether the rashes are caused directly by the virus or whether it is a secondary appearance. Comprehensive research in this direction is still awaited.