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Before the coronavirus outbreak, Dr. Lindy Fox, a dermatologist in San Francisco, used to treat four to five patients a year with chilblains, painful red or purple lesions that usually arise on the fingers and toes in the winter .
In the past few weeks, she has seen dozens.
“Suddenly, we are inundated with toes,” said Dr. Fox, who practices at the University of California, San Francisco. “I have clinics full of people who come in with new finger injuries. And they are not the people who had chilblains before, they have never had anything like that.
It is also not the time of year for chilblains, which are caused by inflammation in small blood vessels in reaction to cold or moisture. “Usually we see it in the dead of winter,” said Dr. Fox.
Dr. Fox is not the only one flooded with cases. In Boston, Dr. Esther Freeman, director of global health dermatology at Massachusetts General Hospital, said her telemedicine clinic is also “completely full of fingers. I had to add additional clinical sessions, just to attend to consultations from feet. People are very concerned. “
Lesions are emerging as another more revealing symptom of infection with the new coronavirus. The most prominent signs are dry cough and shortness of breath, but the virus has been linked to a number of unusual and diverse effects, such as mental confusion and Decreased sense of smell.
Federal health officials don’t include toe injuries on the coronavirus symptom list, but some dermatologists are pushing for a change, saying that the so-called Covid toe should be enough reason to the proof. (Covid-19 is the name of the disease caused by the coronavirus).
Various medical documents from Spain, Belgium and Italy described an increase in complaints about painful injuries to patients ‘toes, Achilles’ heels and soles of the feet; whether the patients were infected was not always clear, because otherwise they were healthy and the evidence was limited.
Most cases have been reported in children, teens, and young adults, and some experts say they may reflect a healthy immune response to the virus.
“The most important message to the public is not to panic: Most of the patients we see with these injuries are doing extremely well,” said Dr. Freeman.
“They are having what we call a benign clinical course. They are staying home, they are getting better, the foot injuries are disappearing.”
Scientists are just beginning to study the phenomenon, but so far chilblain-like lesions seem curiously to indicate a mild or even asymptomatic infection. They can also develop several weeks after the acute phase of an infection ends.
Patients who develop swollen fingers and red and purple lesions should consult their primary care physician or dermatologist to rule out other possible causes. But, experts say, they shouldn’t run to the emergency room, where they risk exposing themselves to the coronavirus or exposing others if they are infected.
“The good news is that chilblain-like injuries generally mean you’re going to be fine,” said Dr. Fox. “It’s usually a good sign that your body has seen Covid and is doing a good reaction. immune to it. “
Patients suffering from painful injuries are often alarmed. They appear most frequently on the toes, often affect multiple toes on one or both feet, and the sores can be extremely painful and cause a burning or itching sensation.
At first, the fingers are swollen and take on a reddish hue; Sometimes a part of the toe is swollen and individual lesions or bumps can be seen. Over time, the lesions turn purple.
Hannah Spitzer, 20, a sophomore at Lafayette College who is remotely completing the academic year at her Westchester County home, has injuries to all 10 toes, so uncomfortable, painful during the day and itching at night, which may ‘do not put anything on your feet, not even socks.
Walking is difficult and she has trouble sleeping. “At first I thought it was my shoes, but it got worse and worse,” Spitzer said. “Most of my fingers are red, swollen, almost shiny. It looks like a freeze. “
She has used hydrocortisone and Benadryl to ease discomfort, and said ice is helpful, too. Doctors say the lesions go away on their own within a few weeks.
In addition to the mystery, some teens and young adults with the lesions have tested negative for the coronavirus.
Dr. Amy Paller, chair of the department of dermatology at Northwestern University’s Feinberg School of Medicine, said a possible explanation is that these patients had such mild disease and that viral replication was limited, causing the virus was undetectable.
Another possibility, he said, is that injuries are what is called an epiphenomenon: a symptom can accompany an illness without being causally related. For example, perhaps more people are developing injuries because they stay indoors and walk barefoot longer than normal.
But he also dismissed that idea as highly unlikely. “I don’t think that’s it, I think it’s a mild inflammatory process that manifests itself this way,” said Dr. Paller. “It is a real phenomenon. We really don’t understand it at all.”
Ms. Spitzer had a test done shortly after developing the injuries, and the result was negative, but she is convinced that the toe injuries are a late response to a previous infection that was so mild that she hardly noticed it.
Most of the patients were teenagers or young adults, including one 15-year-old who discovered he had Covid-19 pneumonia when he went to the emergency room for medical attention for his toes.
Another patient was a 91-year-old man who had been hospitalized with the coronavirus three weeks earlier, and had recovered and returned home.
While dermatologists say it is not unusual for skin rashes to appear alongside viral infections such as measles or chicken pox, the toe injuries surprised them.
Other problems like urticaria have also been linked to the coronavirus, but Covid toes have been the most common and striking manifestation of the skin.
Patients with viral infections often have a pinkish irregular rash called a morbilliform or urticaria, Dr. Fox said, but added that the toe injuries were “unexpected.”
No one knows exactly why the new coronavirus can cause chilblain-like lesions. One hypothesis is that they are caused by inflammation, a prominent feature of Covid-19. Inflammation also causes one of the most serious syndromes associated with coronavirus, acute respiratory distress syndrome.
Other hypotheses are that the lesions are caused by inflammation in the walls of the blood vessels, or by small micro clots in the blood. (Coagulation has been another feature of the disease).
The injuries seen in healthy people appear to be different from what doctors are seeing in some critical patients with intensive care Covid-19, who are prone to developing blood clots.
Some of these clots can be very small and can block small vessels in the extremities, causing rashes on the toes, said Dr. Humberto Choi, pulmonologist and critical care physician at the Cleveland Clinic.
Some experts now believe that the Covid toe should be recognized as a sufficient basis for testing, even in the absence of other symptoms.
“This should be a criterion for testing, as does loss of smell and shortness of breath and chest pain,” said Dr. Fox.
