COVID Toes, COVID Rashes and Other Skin Complications: A Quick Guide

In the years since COVID-19 made its global debut, we’ve learned to expect the unexpected. COVID toes, COVID nails, COVID tongue: It’s wild how many different ways the virus can affect your body. But can it also cause a rash?

In a word: Yes. Pediatric infectious disease specialist Frank Esper, MD, breaks down the most reported COVID-related skin conditions and what to do about them.

Why COVID-19 can cause skin changes

It’s actually quite common to get rashes with viral infections, especially respiratory infections like COVID-19.

“The rash is evidence that our bodies react to infections in many different ways,” says Dr. Esper.

While attention-grabbing and unusual, COVID toes and COVID rashes aren’t signs of life-threatening complications.

“These symptoms may be more common in COVID-19 compared with other viral infections,” he adds. “But they don’t affect a majority of people by any means. And they don’t necessarily mean you’re sicker than somebody else who has COVID.”

Types of COVID-related rashes

When it comes to COVID rashes, one size definitely doesn’t fit all. The kind of skin reaction you have depends on what’s causing it. It could be:

• A strong immune response to the virus (specifically, a robust, type 1 interferon response)
• A side effect of a medication you’re taking to treat it
• An underlying health condition, like eczema, your immune response kicked into high gear

Dr. Esper walks us through the different skin conditions that have been associated with COVID-19.

COVID toes

If you have discolored, painful and itchy spots or lesions on your feet or hands, it could be “COVID toes,” to use the term that was common in the early days of the pandemic.

Many infectious disease specialists now believe that COVID toes are actually just chilblains, painful patches of skin that occur in response to cold air exposure. But there are other explanations, too.

“It’s possible that COVID toe is the result of a small clog or microclots in the blood vessels in the toes. It could also be caused by a narrowing of those blood vessels (vasoconstriction),” Dr. Esper explains. He’s seen similar chilblain-like lesions on ICU patients with sepsis and people on life support. Hives can also be a sign that you’re allergic to a medicine you’re on.

Hive-like rash (urticarial eruption)

Hive-like welts are one of the most common skin conditions to pop up during or after a COVID-19 infection. In fact, it’s sometimes the first sign that you’re sick.

“It’s not unusual to see hives when your immune system is in overdrive, like during allergic reactions or when your body’s fighting off certain viruses,” Dr. Esper reports. “It’s especially common in children.”

Morbilliform (measles-like) rash

Morbilliform rashes are angry red bumps (papules) or raised spots (macules) that can be so numerous that they blend together. This type of rash, which is most commonly associated with measles, usually starts on your back or abdomen and spreads outward.

Like hives, this rash (while still rare) is one of the most common skin-related side effects of COVID-19.

“Many different viruses can cause a morbilliform rash, but so can certain medications,” Dr. Esper says. “It could be that something you’re taking to address your COVID symptoms is causing the skin reaction.”

Petechiae or purpura

While sometimes referred to as a rash, petechiae and purpura are actually caused by bleeding under the skin, not inflammation of the skin.

The main difference between petechiae and purpura is their size. Petechiae are tiny red spots, less than 2 millimeters wide, caused by burst capillaries, the smallest blood vessels in your body.

Purpura, on the other hand, is the result of damage to multiple capillaries or larger blood vessels. The result? Larger spots — sometimes up to an inch wide — that sport a red, brown or purple hue.

“Call your provider if you notice petechiae or purpura,” Dr. Esper stresses. “It could be a sign that there’s a more serious underlying condition that needs to be addressed, beyond COVID.”

Vesicular (chickenpox-like) rash

If you’ve had chickenpox, shingles or herpes, you’ve had a virus-induced vesicular rash. While rare, there are reports of the same thing happening to some people while sick with COVID-19.

The rash has four basic stages:

1. You develop red, pink or brown bumps (depending on your skin color). These bumps are often itchy and tender.
2. Over time, the bumps turn into fluid-filled blisters called vesicles.
3. While not all vesicles break, some usually do, either because you scratched or because they burst on their own. The ruptured vesicles dry out, leaving a scab behind. If the skin is badly damaged or the wound becomes infected, you may develop skin ulcers.
4. As you recover, the vesicles that stayed intact dry out and slowly reabsorb into your skin and the ulcers heal. Both can leave behind damaged, dry skin. Scarring and hyperpigmentation are unlikely but possible.

Research suggests that a COVID-related vesicular rash should resolve in about 10 days.

Livedo reticularis (mottled skin)

Livedo reticularis isn’t a rash, but it does change the appearance of your skin. It’s a bluish red, lace-like pattern you see under your skin. It can happen for all sorts of reasons, some minor and some major.

When it happens with COVID, it’s a sign that the virus is somehow impacting your circulation.

“Mottled skin isn’t dangerous, but vascular complications from COVID can be,” Dr. Esper explains. “I’d recommend seeing your provider just to rule out a more serious issue. It’s always better to be safe than sorry.”

How to tell if a skin rash might be COVID

There’s only one way to know if a sudden change to your skin is a sign that you have COVID-19: Take a COVID-19 test.

“Mercifully, we’re past the stage of the pandemic where we can’t be sure whether or not we’re infected,” Dr. Esper says. “The bigger question is whether your skin symptoms are COVID-related or there’s something else going on.”

Diagnosis

If you test positive for COVID-19 and have skin symptoms, Dr. Esper recommends contacting your healthcare provider. They may prescribe medication to treat your skin or toes. And if your age or health status raises your risk of complications, they may suggest going on an antiviral like Paxlovid® or Molnupiravir®.

Treatment

Most of the time, a rash with COVID-19 requires little or no treatment. But it’s still important to tell your provider about it and monitor your condition closely. If you notice something about your skin changing, it could be a sign that you’re experiencing a more serious COVID-19 complication. (More on that later.)

Treating COVID toes

While we don’t yet know whether “COVID toes” are actually chilblains, Dr. Esper says the treatment is the same.

“Most of the time, chilblains go away on their own without treatment within a couple of weeks,” he reports. “If you’re struggling with pain, itching or the lesions don’t seem to be going away, call your provider. They can prescribe topical and oral medications to speed up your recovery.”

Treating other rashes

While they may be a rare response to the COVID-19 virus, COVID rashes tend to be mild and short-lived. They’re often treated at home with:

• Cold compresses
• Sensitive-skin-friendly moisturizers
• Over-the-counter antihistamines and topical steroids like hydrocortisone cream
• Over-the-counter anti-inflammatory medications
  (Just don’t double up! If you’re taking a fever reducer, you’re already getting the medication you need to calm your rash.)

How long do viral and post-viral rashes last? Dr. Esper says it depends on the type you’re dealing with, whether you’re scratching and more. If your skin hasn’t improved within a week (or if it’s worsening), follow up with your provider.

Complications to watch for

COVID toes and COVID rashes are a minor inconvenience, but if you notice significant changes to your skin symptoms, it could be a sign of a more serious complication, like a bacterial infection or vasculitis.

It could also mean you have another illness, like mononucleosis (mono) or meningitis, at the same time that you’re dealing with COVID-19. Talk about bad luck!

Let your doctor know if:

• The rash is spreading rapidly.
• Your skin is swelling and hot to the touch.
• The rash is bleeding or weeping fluid.
• Your skin looks badly bruised.

“If your COVID rash is causing serious itching or pain, that’s reason enough to call your provider,” Dr. Esper emphasizes. “Some discomfort is expected, but severe symptoms should be investigated.”

When to see your doctor

Call a provider if you test positive for COVID-19 and are experiencing skin symptoms. They’ll look at the rash to confirm that it’s a side effect of your infection and — if needed — prescribe medication to help manage your symptoms.

COVID toes and rashes aren’t an emergency, but COVID-19 can be. Call 911 or emergency services if you tested positive and are:

• Having chest pain, tightness or pressure
• Dizzy, lightheaded or had a fainting episode (syncope)
• Struggling to breathe
• Exhausted to the point of being unable to stay awake
• Feel confused or there’s a sudden change in your mental state