Medical experts explain the different skin manifestations of coronavirus infection and what causes them, from pseudo-chilblains to livedo reticularis.
COVID-19 has long been known to attack the lungs and respiratory system. But research published in the British Journal of Dermatology shows the virus can also set off a range of unexpected skin conditions — from swollen, itchy toes that look like chilblains to rashes and flare-ups of existing skin problems. Dermatologists now accept that the skin may be one of the earliest indicators of coronavirus infection, and in some cases the only visible sign.
How ‘COVID Toes’ Were First Discovered
It started in Spain. In May 2020, dermatologists there noticed a pattern among confirmed COVID-19 patients: red or purple swollen toes and fingers, quickly dubbed “COVID toes” or “pseudo-chilblains.” The lesions looked like traditional chilblains — the small, itchy swellings you get after cold exposure — except these patients hadn’t been anywhere near the cold.
Since then, the picture has grown far more detailed. The skin, it turns out, can respond to COVID-19 in at least five distinct ways.
What UK Research Found
Researchers at Luton and Dunstable University Hospital examined 93 confirmed COVID-19 patients during the first pandemic wave. Forty per cent developed some form of skin lesions, but only 5.5% had skin changes the team could tie directly to the virus. Two patterns stood out: pseudo-chilblain lesions on the hands and feet, and purpuric livedoid lesions — darker, net-like marks on the skin linked to more severe illness.
Five Distinct Skin Manifestations Identified
The largest UK dataset came from the ZOE COVID Study app. Nearly 349,000 users reported their symptoms, and the data pointed to five cutaneous manifestations:
- Acral rashes — red or purple sores on feet or toes
- Burning rashes with pins-and-needles sensations
- Erythematopapular rashes on the arms and torso
- Urticarial rashes — red, itchy welts or sudden facial swelling
- Unusual hair loss
Skin problems were more common during the Delta wave, showing up in 17.6% of infections versus 11.4% with Omicron. Most lasted between seven and nine days.
Severity and Skin Symptoms
Here’s where it gets counterintuitive. Mild or asymptomatic infections tend to produce the inflammatory rashes and COVID toes. The more worrying vascular lesions — livedoid or purpuric patterns that suggest blood vessel damage — crop up in sicker patients and point to a worse prognosis.
“Most skin lesions are probably a result of COVID’s effects on the vascular or immune systems, rather than widespread direct viral infection of skin cells,” the researchers concluded.
Why the Skin Reacts to COVID-19
The virus latches onto ACE2 receptors, which are present in skin tissue. That triggers endothelial dysfunction — essentially, damage to blood vessel linings — causing localised inflammation and making the blood more prone to clotting.
In milder infections, the rashes appear to be driven by the immune system’s response rather than the virus directly attacking skin cells. Multiple studies have gone looking for viral material in skin biopsies and come up largely empty-handed, confirming that SARS-CoV-2 rarely infects skin tissue directly.
Not All Skin Changes Are Caused by the Virus
Worth noting: not every skin problem that appeared during the pandemic was caused by COVID itself. Hand dermatitis, facial eczema, and flare-ups of existing conditions were often down to behavioural changes — obsessive hand washing, alcohol-based sanitisers, and hours spent in PPE. Lockdown stress likely played a role too.
Treatment and Vaccination
The good news is that most COVID-related rashes clear up on their own. Topical steroids and antihistamines help with itching, and standard wound care covers the rest. The vascular lesions seen in severe disease are a different matter — those need proper medical assessment.
As for vaccines, they didn’t appear to reduce the overall risk of skin symptoms, though vaccinated individuals did report fewer burning rashes than those who were unvaccinated.
When to Seek Medical Advice
A new, unexplained rash should prompt a COVID-19 test, especially if you’ve recently been exposed to the virus or have other symptoms. Research from King’s College London found that skin rashes and COVID fingers and toes can appear with no respiratory symptoms at all — making them an important diagnostic clue that’s easy to miss.
Source: @bmj_latest
Key Takeaways
- COVID-19 can cause five main types of skin reaction: acral rashes on feet and toes, burning sensations, erythematopapular rashes on limbs and torso, urticarial rashes with facial swelling, and unusual hair loss
- Skin rashes tend to appear during mild or asymptomatic infection, while severe disease may present with vascular lesions tied to worse outcomes
- Most COVID-related skin conditions clear up without treatment; an unexplained rash is worth a COVID test, particularly after recent exposure
What This Means for Kent Residents
If you develop an unexpected rash, swollen or itchy toes, or unusual skin symptoms alongside possible COVID-19 signs, the NHS recommends testing and contacting your GP. Residents across Kent and Medway can access COVID-19 testing through NHS services and get advice from their local GP surgery. If existing skin conditions like eczema or psoriasis have flared during or after a COVID infection, your GP can refer you to specialist dermatology services through the NHS Kent and Medway ICB. The NHS website remains the most reliable source for general skin health guidance.
