COVID Toes and the Pregnant Woman

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Lately, we have been hearing a lot about how COVID-19 can affect more than just the lungs. We have seen from patients who have been infected with SARS-CoV-2 (the virus that causes COVID-19) that it can affect many other organs—for example, the heart and the kidneys, and even the placenta in pregnant women.

Perhaps most puzzling is the skin rash that has become known as “COVID toes.” Though there is no widespread consensus on the actual cause of COVID toes, it is thought that the same pathology may underlie all of these manifestations. In other words, the way novel coronavirus attacks the blood vessels after it gains entry through the upper respiratory system and lungs can lead to COVID toes as well as affect all of the aforementioned organs.

Viral rashes

COVID toes is not the only rash physicians have seen in patients who have become infected by a virus. It’s not unusual at all that a viral infection is associated with a skin rash. In fact, there are a number of common viruses associated with rash, among them are chickenpox, fifth disease, rubella, and mononucleosis. Sometimes, we even see nonspecific rashes develop with the flu or the common cold. Everyone’s immune system is different. One reaction to a viral infection (seen especially in children) is a rash.

Though there is no widespread consensus on the actual cause of COVID toes, it is thought that the same pathology may underlie the heart, kidney, placenta, multisystem inflammation, and skin conditions that have been associated with COVID-19.

COVID toes

As stated above, COVID-19 not only affects the lungs, it also affects the heart, kidneys, and the placenta in pregnant women, and can lead to the Kawasaki-like disease termed MIS-C (or, multisystem inflammatory syndrome in children). It isn’t surprising, then, that infection with COVID-19 can also affect the skin. There are quite a few skin conditions that have been associated with COVID-19.

Skin disorders that have been seen with COVID-19 infection include:

  • Pseudo-chilblains (COVID toes, associated with milder disease course, seen later in the disease)
  • Chickenpox-like lesions
  • Maculopapular rash (could be similar in appearance to allergic hives, associated with more severe disease course)
  • Livedo (reddish purple and net-like in appearance, associated with more severe disease course)
  • Necrosis (associated with more severe disease course)

One of the skin conditions we’re hearing a lot more about lately is a rash known as COVID toes. This rash, when it presents, usually does so later in the course of the disease and is usually seen in younger patients that have had a mild disease course.

Though there is no widespread consensus on the actual cause of COVID toes, it is thought that the same pathology may underlie the heart, kidney, placenta, multisystem inflammation, and skin conditions that have been associated with COVID-19. That pathology begins once the virus gains entry to the body via the respiratory system. The virus then goes on to attack the smooth interior lining, called the endothelium, of the blood vessels. Disrupting the endothelium can cause clots to form in the blood vessels. The damage can also cause previously stable plaques to break off and travel to other vessels. The formation of clots or plaques that travel through the circulatory system can interfere with blood flow in any organ.

What is pseudo-chilblains?

To better understand the phenomenon of COVID toes, the condition has been compared to chilblains. Chilblains is usually limited to people who have been exposed to extreme cold. Painful or itchy lesions develop in the digits (fingers, toes) or other extremities, such as the nose and ears, due to inflammation of tiny blood vessels. The condition usually resolves quickly.

COVID toes has been called pseudo-chilblains because it is seen as the same type of phenomenon, including the painful or itchy lesions on the extremities. However, the patients who have pseudo-chilblains have not been exposed to a cold climate. The thing these patients have been exposed to, it turns out, is SARS-CoV-2.

Implications for the pregnant patient

The data we have regarding how pregnancy is affected by infection with COVID-19 is sparse. COVID toes could be an indication that a patient has been infected with SARS-CoV-2. The condition could also be an indication that blood supply in the tiny vessels of the extremities may have become compromised. The worry is that the blood supply to the fetus, via the placenta, may also become compromised. If this blood supply is interrupted, it could lead to a host of problems for both mother and fetus. If you are at all concerned that you have COVID toes, or that you may have come down with the virus at any point during your pregnancy, contact your physician.

Janette DeFelice
Dr. Janette DeFelice is a writer currently focusing on how the changing environment affects our health. She holds a Doctor of Medicine degree from Chicago Medical School where she taught clinical and diagnostic skills to beginning medical students, and a Master’s degree in Humanities from the University of Chicago. She also has a Bachelor’s degree in Political Science. Her writing can be seen online at BeTheChangeMom, ChicagoNow, and Medium, and she’s very excited to have published her first novel, Delia Rising: A Ballet in Three Acts. She lives in Chicago’s west suburbs with her school-age twins, her husband, and a family cat named Clara Barton.

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