COVID19 causes purple toes!

In medicine, not many things really surprise me! As a rheumatologist I am used to seeing uncommon diseases and unusual presentations of diseases. However, this recent COVID-19 has us all puzzled and confused with various unpredictable manifestations. Being a rheumatologist I work with many specialties closely to either manage or co-manage patients with rheumatological illnesses. I recently had a pleasure of talking with our local dermatologist Dr. Alissa O’Brien about skin manifestations of COVID-19. In order to educate our local healthcare providers and community, Dr. O'Brien has agreed on doing a guest post for my educational blog series on COVID-19.

About Dr. Alissa O’Brien:

She grew up in Jupiter, Florida, and graduated from the international baccalaureate program at Suncoast High School. Dr. O’Brien received a medical degree and completed her dermatology residency at the University of Florida College of Medicine in Gainesville, Florida where she served as chief resident. Dr. O’Brien treats patients of all ages, including children. She is an affiliate staff member at Jupiter Medical Center where she helped establish and co-direct the JMC Cutaneous Oncology Program. In 2019, Dr. O’Brien was recognized by her medical peers as one of Palm Beach Illustrated’s “Top Doctors.” She has also served as a courtesy clinical assistant professor at the University of Florida Department of Dermatology.

Guest post on COVID-19 skin manifestations by Dr. O'Brien:

· COVID-19 can cause purple to red often painful spots on the digits (toes and less commonly fingers) - can be spots/patches or can encompass a whole digit.

· Best medical term would be Perniosis-like lesions (or Chilblains-like lesions)

· Perniosis (non-COVID type) is rare in FL because it’s usually a disease of cold-weather - thus a new rash like this should raise your alert for COVID-19

Why COVID-19 causes these rashes?

• Mechanism by which the virus causes this phenomenon is still unknown - Some theories suggest may be a micro-thrombotic event (vs vasoconstriction or inflammatory).

Who can get it?

• Often seen in children, adolescents, or young adults with COVID-19, but can occur in COVID-19 patients of any age.

• Can be seen in symptomatic or otherwise asymptomatic COVID-19 cases (may be the only sign of COVID-19).

Is the rash dangerous?

• The rash itself is not thought to be dangerous

• May occur early in COVID-19 infection or later, including weeks after infection

What should be done?

• If you see a new onset pernio-like rash you should think of COVID-19 & tell your patient to self-isolate for 14 days & attempt to get testing via the public health department (nasal swab test for acute infection). If the patient had respiratory symptoms 3+ week ago then consider the antibody test instead, if available.

Are there any other kind of rashes with COVID-19?

• Other rashes that may be seen in COVID-19 patients include:

• Livedoid rash (see picture below)

• Many patients have a normal baseline livedoid appearance especially on their thighs HOWEVER new onset of especially on single area that may be painful raises concern for COVID-19

• Petechiae (red/purple non-blanchable spots)– consider emergency & get labs ( For Physicians and health care providers: you will need cbc with diff, platelets and peripheral smear/PT/PTT/INR/fibrinogen/d-dimer/anti-phospholipid Ab/cryoglobulins/CMP/bloodCx/UA/stool occult & other pertinent labs on case-by-case basis due to broad differential diagnosis)

• Urticaria (hives/wheals) – broad differential diagnosis

• Viral exanthem (usually red maculo-papular diffuse rash on trunk and extremities and sometimes face) – broad differentials

* Physicians and other healthcare providers: You should enter any rashes you think likely associated with COVID-19 into the American Academy of Dermatology COVID-19 Database: https://www.aad.org/member/practice/coronavirus/registry

* You can read more on the skin manifestations of COVID-19 in the articles below:

https://nypost.com/2020/04/14/foot-sores-could-be-an-early-sign-of-coronavirus-experts-say/

https://www.mdedge.com/dermatology/article/220183/coronavirus-updates/skin-manifestations-are-emerging-coronavirus-pandemic

https://consultqd.clevelandclinic.org/skin-rashes-an-emerging-symptom-of-covid-19/

Alissa O’Brien MD (board certified dermatologist)

1096 W Indiantown Rd.

Jupiter 33458

P: 561-222-2200

www.wederm.com