Dermatologists are scratching their heads over frostbite-like lesions that are appearing on the toes of mainly children and young people who have been diagnosed with asymptomatic or mild cases of COVID-19. In some cases, the lesions have appeared on the patient’s fingers.

The sometimes burning condition has been nicknamed “COVID toes” by researchers, yet it’s unclear whether the red or purple rash is a symptom of COVID-19 or a consequence of a second virus carried by the patient.

In many cases, patients presenting with COVID toes haven’t actually been tested for the virus.

The mystery of COVID toes has somewhat overshadowed the emerging problem of rashes, hives and lesions that are appearing all over the body on some COVID patients, suggesting the illness directly manifests skin conditions.

An alert from the American Academy of Dermatology Association illustrating some of the skin purportedly associated with COVID-19. Image: AADA

In most cases, the toes and torsos tend to recover in a couple of weeks. Even if the breakouts are a consequence of COVID, it’s unlikely they’d be considered a diagnostic symptom of the disease.

Hives and rashes are common in children suffering respiratory and other viral infections.

The issue of COVID skin conditions emerged in late March, after a group of Italian dermatologists collected data from 88 COVID-19 patients from the Lombardy region: 18 patients (one in five) had developed rashes or chickenpox-like vesicles.

Eight of the patients developed the skin problems at the onset of the disease, and the other 10 developed problems after hospitalisation.

In a letter to the Journal of the European Academy of Dermatology and Venereology, one of the investigators, Dr Sebastiano Recalcati, advised:

“The trunk was the main involved region. Itching was low or absent and usually lesions healed in few days. Apparently there was not any correlation with disease’s severity.”

In early April, French dermatologists reported skin outbreaks, including lesions on the toes, which they termed “pseudo frostbite”, among likely COVID-19 patients.

Since then, the American Academy of Dermatology, has listed more than 100 cases of pseudo-frostbite on a symptoms register, where the catchy “COVID toes” nickname was reportedly coined.

But the shortage of testing kits means the COVID connection remains unproven.

In a prepared statement, Northwestern Medicine dermatologist Dr. Amy Paller said she has collected images of approximately 30 cases of COVID toes. She said more testing is needed to definitely know what is causing the condition.

“We don’t know for sure if it’s related to COVID-19, but when it’s so common right now during a pandemic and is occurring in otherwise asymptomatic or mildly affected patients, it seems too much of a coincidence not to be a manifestation of the virus for patients in their teens and 20s,” said Dr Paller, the chairman of dermatology at Northwestern University Feinberg School of Medicine.

“I think it’s much more rampant than we even realise. The good news is it resolves spontaneously.”

Dr Humberto Choi, a pulmonologist at the Cleveland Clinic, said in a hospital online posting: “It’s not uncommon for someone to have a viral infection and have a rash or blotchy areas on their body. This can happen with other viral respiratory infections like measles. And sometimes, antibiotics might cause skin rashes.”

Dr Choi suggested that, like rashes, COVID toes were just another way the body can respond to a viral infection.

“It’s a different form of manifestation and it is still not very clear what causes it. One pattern of COVID toes that people are reporting is red lesions typically on the soles. It’s possible that this is a skin reaction or caused by a small clog or micro clots in the blood vessels found in the toes,” Dr Choi said.

Dr Alisa Femia, director of inpatient dermatology and a specialist in autoimmune connective tissue disease at NYU Langone, in an interview with TIME magazine, said she was seeing “COVID toes fairly frequently these days, often among people with few other symptoms of COVID-19 calling for telemedicine consults from home.”

But she cautioned that other viruses could be to blame, and that the intense focus on all matters COVID could be leading doctors astray.

“Everybody’s looking at things through COVID goggles right now,” Dr Femia told TIME.

“You have to have a sceptical eye.”’

Professor Peter Collignon is an Infectious Diseases Physician and   Microbiologist with the Australian National University.

He told The New Daily that a patient with COVID-19 could be suffering a second, different virus. He cautioned doctors not to assume that everything  presenting in a COVID-19 patient was actually related or caused by COVID-19.

Professor Collignon said that some of the images he’d seen “looked like foot and mouth disease,” a viral infection that causes a rash or blisters on the hands and feet, as well as in or around the mouth.