To describe clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19. Inclusion in an NLM database does not imply endorsement of, or agreement with, COVID toes: Pernio-like lesions Clin Dermatol. The urticarial, morbilliform, exanthematous eruptions described seem thus far both nonspecific and inconsistent enough to aid in either making a diagnosis or offering prognostic interpretations, but as with the rest, warrant monitoring. HHS Vulnerability Disclosure, Help National Library of Medicine Disclosure: I am a member of the AAD Ad Hoc Task Force on COVID-19 and the Medical Dermatology Societys Ad Hoc Task Force, and involved in the AADs COVID-19 registry referenced above (Director: Esther Freeman). Given the association between the new onset of perniolike manifestations and COVID19 infection, [Epub ahead of print], Henry D, Ackerman M, Sancelme E, Finon A, Esteve E. Urticarial eruption in COVID-19 infection. This week I had a teledermatology consult on a COVID-19 patient who clearly had chronic submammary intertrigo I teased my resident: Mike, you better write this up quickly as the first case of chronic intertrigo reported in COVID-19!, Image with permission from Analisa Halpern, MD, The diagnosis of COVID-19 is based on clinical signs (fever, fatigue, dry cough, anorexia, dyspnea, rhinorrhea, ageusia, anosmia), on vital parameters (temperature, pulse oximetry saturation), and on radiological findings (X-ray, chest CT scan). Immunocompromised patients may fail to generate antibodies, but most patients with COVID-19associated pernio-like lesions are otherwise healthy young patients whose skin lesions developed late in their course with theoretically sufficient time to generate IgM or IgG antibodies, or both. When interferon tiptoes through COVID-19: Pernio-like lesions and their prognostic implications during SARS-CoV-2 infection. We do not endorse non-Cleveland Clinic products or services Policy. Pernio-like lesions were common in patients with mild disease, whereas retiform purpura presented exclusively in ill, hospitalized patients. Perhaps such coagulopathies could be contributing to LR or other acral pernio-like lesions. Oxley T.J., Mocco J., Majidi S. Large-vessel stroke as a presenting feature of Covid-19 in the Young. Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. Like urticaria, vesicular eruptions were also commonly noted before other COVID-19 symptoms (in 8.5% to 15% of cases of COVID-19-associated urticaria) in multiple studies, and therefore may similarly provide an indication for COVID-19 testing and isolation in the appropriate clinical context. The promise and peril of antibody testing for COVID-19. Check out DermWorld Insights & Inquiries for the latest updates from Dr. Warren Heymann. It will take heroic efforts to overcome COVID-19, and we should be raising our voices to advocate for what is necessary to hold this disease in check until there are effective treatments and/or a vaccine. The website (www.aad.org/covidregistry) was hosted through a Massachusetts General Hospital REDCap (Research Electronic Data Capture, Vanderbilt University, Nashville, TN) database. Chilblains outbreak during COVID-19 pandemic: A Type-I interferonopathy? Given current testing criteria, many patients lacked COVID-19 testing access. There may be confirmation bias in reporting of cases. J Am Acad Dermatol 2020 Apr 10. pii: S0190-9622(20)30556-9. doi: 10.1016/j.jaad.2020.04.016. Ladha MA, Luca N, Constantinescu C, Naert K, Ramien ML. For exhibitors, advertisers, sponsors & media, Running Your Dermatology Practice During COVID-19, What are Covid toes? Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. Laboratory findings demonstrate lymphopenia and an elevated LDH. Viral exanthem in COVID-19, a clinical enigma with biological significance. [Epub ahead of print], Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for Dengue. While the debate continues, if these lesions are truly a COVID-19 manifestation, they are, fortunately, associated with high survival rates (96.4% to 98.7%) and few or no systemic symptoms. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Additionally, a systematic review reported a possible link between vesicular eruptions and neurologic symptoms, including headache, dysgeusia, irritability and confusion. Pernio-like lesions lasted a median of 14 days (interquartile range, 10-21 days). Epub 2020 Oct 1. J Eur Acad Dermatol Venereol. The pernio-like lesions in most patients developed either concurrently with, or after, COVID-19 symptoms, although 174 patients with confirmed or suspected COVID-19 presented only with pernio-like skin lesions. Learn about the Academy's advocacy priorities and how to join efforts to protect your practice. For example, in the article What are Covid toes? [e-pub ahead of print]. We established a registry to collect cases of COVID-19 with dermatologic manifestations reported by medical professionals, with data collected from April 8, 2020, to May 2, 2020. Chilblain-like lesions during the COVID-19 pandemic: should we really worry? Future studies are needed to assess the histopathology of pernio-like lesions to inform understanding of the disease process. These cases represent novel cases of new-onset pernio in patients without prior history, temporally associated with high levels of undetected community-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) circulation during the COVID-19 pandemic. The open-access and fully referenced original article is available here. Catanzaro Int J Dermatol. The https:// ensures that you are connecting to the Additionally, it is important to consider alternate explanations for these cases of pernio. Herpes simplex virus (HSV) and varicella-zoster virus (VZV) reactivations have been reported in conjunction with COVID-19 infection. Interestingly, in a systematic review of 895 patients with COVID-19, 105 (12%) had urticarial lesions, and in 17 (16%) of these 105 the urticaria began before the onset of the other COVID-19 symptoms, suggesting that it can be a clue to diagnosis in appropriate clinical settings and can help guide early testing. We would like to thank the International League of Dermatological Societies for their international collaboration. The Academy has developed quality measures to help your dermatology practice. National Library of Medicine 2020;83(2):700. We present the case of a 60-year-old patient who reported the onset of pernio-like lesions on both hands . Galvan Casas C., Catala A., Carretero Hernandez G. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. , Two days later she was febrile with chest pain, testing positive for COVID-19. J Am Acad Dermatol. The patient subsequently developed respiratory problems which proved to be COVID-19. Fiehn C. Familial chilblain lupus-what can we learn from type I interferonopathies? Careers, Unable to load your collection due to an error. Conflicts of interest: Drs Freeman, Lipoff, Rosenbach, Kovarik, Takeshita, Hruza, and Fox are part of the American Academy of Dermatology (AAD) Covid-19 Ad Hoc Task Force. New Engl J Med 2020 Feb 28 doi: 10.1056/NEJMoa2002032 [Epub ahead of print]. Disclaimers: This commentary was written on April 17, 2020 for a publication date of April 22, 2020. Clin Dermatol. sharing sensitive information, make sure youre on a federal -. Vol. New developments in COVID-19 antibody testing may further clarify the timing of pernio-like lesions in the COVID-19 clinical course. Epub 2020 Jun 5. , In this video, Amy Paller, M.D., professor and chair of dermatology at Northwestern Feinberg School of Medicine, discusses these skin lesions and how they may be connected to the COVID-19 pandemic . 4 The content included in this commentary may no longer be factual or relevant by the publication date. Accessibility Test performance evaluation of SARS-CoV-2 serological assays [preprint], Wu F., Wang A., Liu M. Neutralizing antibody responses to SARS-CoV-2 in a COVID-19 recovered patient cohort and their implications [preprint]. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19. J Eur Acad Dermatol Venereol 2020 Apr 15. doi: 10.1111/jdv.16474. Patients in this case series were generally young, with few comorbidities, and had benign clinical courses. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19. Read this month's top stories in Dermatology World. Lesions tend to resolve after about eight days without scarring. [Epub ahead of print], Manalo IF, Smith MK, Cheeley J, Jacobs R. A dermatologic manifestation of COVID-19: Transient livedo reticularis. 9500 Euclid Avenue , Cleveland , Ohio 44195 | 800.223.2273 | TTY 216.444.0261, What Long COVID Means for Rheumatologists (Video), Cutaneous Manifestations of COVID-19 in Special Populations, Effects of COVID-19 on Blood Sugar and Type 2 Diabetes, Optimal Management of High Risk Immunocompromised Patients in the COVID-19 Era, Morbilliform rash (containing macules and papules, resembling measles), Pseudo-chilblains (also known as COVID toes, painful inflammation of the digits in response to cold), Vaso-occlusive lesions (due to thrombosis and occlusion of small arteries, with subsequent ischemia). He died of his illness 3.5 weeks after admission. FOIA Based on these data, we propose that this finding should prompt evaluation for the active or convalescent phase of infection. 8%) of the 103 cases with pernio were long-haulers with pernio lasting for more than 60 days, of whom two cases were laboratory-confirmed. Like those with morbilliform rash or urticaria, patients with COVID-19 with vesicular eruptions have high survival rates (96.1% to 96.6%). Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. 2020;34(5):e212e213. Another brilliant colleague, Dr. Joanna Harp (a skin serious dermatologist making a real difference on the front-lines), rounding daily in the ICU in heavily-hit Manhattan, observed skin changes ranging from livedo racemosa to retiform purpura, with intravascular thrombi on biopsy. Patients with pernio-like lesions of COVID-19 may still be infectious and pose a public health risk, because skin lesions developed in at least 4 patients in this report before COVID-19 PCR confirmation, and the lesions developed in 14 while still PCR positive. Idiopathic pernio is traditionally seen in cooler, damp climates and it may be a coincidence that COVID-19 is devastating North America right as damp spring is occurring. J Eur Acad Dermatol Venereol. 8600 Rockville Pike government site. Skin biopsy is generally not performed as this clinical condition is not characterized by specific histopathology. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. We have reviewed the published case series on "COVID toes" in addition to studies identifying possible pathogenic mechanisms behind the eruption. [e-pub ahead of print]. Genovese G, Moltrasio C, Berti E, Marzano AV. The patient in this manuscript has given written informed consent to the publication of her case details. American Academy of Dermatology Ad Hoc Task Force on COVID-19, See this image and copyright information in PMC. Department of Health Sciences, Approach to Chilblains During the COVID-19 Pandemic [Formula: see text]. Galvn Casas C, Catal A, Carretero Hernndez G, et al. DM @diagnose_it to buy our CASE SERIES BOOKS 127 cases with ." In nonepidemic settings, pernio is often idiopathic or related to underlying disease (eg, systemic lupus erythematosus or antiphospholipid antibody syndrome), and cannot easily be ascertained with histopathology alone.11 The histopathology reported for 1 of the COVID-19 PCR-positive patients, as well as 4 of 6 patients with suspected COVID-19, demonstrated features consistent with pernio without evidence of vascular damage, suggesting COVID-19associated pernio-like lesions may be simply inflammatory. Would you like email updates of new search results? Reflecting innate immune activation, levels of many pro-inflammatory effector cytokines, such as TNF, IL-1, IL-6, IL-8, G-CSF, and GM-CSF, as well as chemokines, such as MCP1, IP10, and MIP1, are elevated in patients with COVID-19, with higher levels in those who are critically ill. Pernio-like skin . 2020 Nov;183(5):866-874. doi: 10.1111/bjd.19377. International registry data indicate that morbilliform eruptions are the most common cutaneous manifestation in patients with laboratory-confirmed COVID-19. Yet, despite the tribulations, the heroic determination to conquer the ravages of this novel coronavirus has been the impetus for the acquisition and dissemination of new knowledge. COVID-19: risk for cytokine targeting in chronic inflammatory diseases? Postinflammatory desquamation at site of. Our case series demonstrates pernio-like skin lesions as a manifestation of COVID-19. Br J Dermatol. Pernio-like skin changes of the feet and hands, without another explanation, may suggest COVID-19 infection and should prompt confirmatory testing. Our objectives were to assess location, timing, and duration of the pernio-like lesions, and to analyze patients' comorbidities, COVID-19 severity, and disease outcomes. Conclusions: There is evolving evidence suggesting that skin manifestations may occur in some COVID-19 patients. Typical clinical features include a generalized, symmetric maculopapular rash with pruritus. government site. Tan W., Lu Y., Zhang J. Questions remain about patients who presented with pernio-like changes and presumed COVID-19 who were ultimately PCR negative. Chilblain-like symptoms have also been linked to COVID-19. Case presentation. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19. 2022 Oct 19;2(10):e0000488. Find practical guidance on coding issues common in dermatology practices. 5 Pernio, or chilblains, is a superficial inflammatory vascular response that occurs on acral skin, usually after cold exposure, typically in children and young to middle-aged women.6 In this large international registry-based case series, we evaluate clinical characteristics of patients with suspected or confirmed COVID-19 who presented with pernio-like lesions on acral surfaces. Two of these patients were PCR negative but IgM positive. No abstract available. Cleveland Clinic is a non-profit academic medical center. Limitations of this case series include incomplete testing for COVID-19, especially in otherwise asymptomatic patients. ). Wang D., Hu B., Hu C. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. Given current testing criteria, many patients lacked COVID-19 testing access. According to Schett et al, COVID-19 leads to fast activation of innate immune cells, especially in patients developing severe disease. Paraviral eruptions in the era of COVID-19: Do some skin manifestations point to a natural resistance to SARS-CoV-2? Copyright 2020 American Academy of Dermatology, Inc. 7 and transmitted securely. Results: Given the press surrounding COVID-toes and well-earned fear of COVID-19, patients with these sometimes subtle skin findings may be seeking more medical attention than they otherwise would for relatively innocuous lesions, leading to an uptick in diagnosis. Inclusion in an NLM database does not imply endorsement of, or agreement with, Neither patient was critically ill. Cleveland Clinic 1995-2023. 2020 Aug;83(2):486-492. doi: 10.1016/j.jaad.2020.05.109. HHS Vulnerability Disclosure, Help Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. 2020 Nov-Dec;38(6):764-767. doi: 10.1016/j.clindermatol.2020.06.002. 2020;370:8994. The rapid and complete transformation of our world health and economy is spellbinding, disorienting, heart wrenching, and devastating. Clipboard, Search History, and several other advanced features are temporarily unavailable. Some patients who did receive testing had negative results: of 318 patients with pernio-like lesions, 46 were PCR negative and 14 were antibody negative. Explore hundreds of Dermatology World Insights and Inquiries articles by clinical area, specific condition, or medical journal source. Pruritus was minimal or absent and lesions usually healed in a few days. Circulating neutrophil numbers are consistently higher in survivors of COVID-19 than in non-survivors, and the infection also induces lymphocytopenia that mostly affects the CD4+ T cell subset, including effector, memory, and regulatory T cells. , Immunological factors presumably contribute to the pathogenesis of cutaneous lesions. , official website and that any information you provide is encrypted Recalcati, a dermatologist in Italy, collected data on 88 COVID-19 patients 18 patients (20.4%) developed cutaneous manifestations; 8 patients developed cutaneous involvement at the onset, 10 patients after hospitalization. and transmitted securely. However, Warren touched on another key point: not everything we see is COVID-19 related. The authors hypothesized that the LR may have been due to microthromboses in these patients, possibly from a low-grade DIC. Dr Thiers is the president of the AAD. A case series cannot estimate population-level incidence or prevalence. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Importantly, although young patients with COVID-19 have presented with stroke, we are not aware of any cases of concomitant pernio-like lesions and strokes.19. Mensa-Vilar A, Vicente A, Espaol-Rego M, Antn J, Fabregat V, Fortuny C, Gonzlez EA, Fumad V, Gonzlez-Roca E, Jou C, Plaza S, Mosquera JM, Yage J, Prat C, Pascal M, Juan M, Arostegui JI, Baselga E, Alsina L. Pediatr Allergy Immunol. The clinical features do not appear to differ from those of idiopathic urticaria and typically consist of generalized pruritic wheals. 8 2023 Jan;22(1):4-10. doi: 10.1111/jocd.15477. Epub 2020 Jun 19. However, some reports describe prominent keratinocyte acantholysis contributing to formation of intraepidermal vesicles, which is a relatively unusual histologic finding. To evaluate and summarize the clinical, laboratory, and histopathological characteristics of pernio-like lesions reported in the literature. We documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions. J Cutan Med Surg. The most common were cough (21%), headache (15%), sore throat (12%), and fever (12%). [Epub ahead of print], Zhang Y, Xiao M, Zhang S, Xia P. Coagulopathy and antiphospholipid antibodies in patients with COVID-19. Pernio lesions are generally idiopathic and, in some cases, secondary to other diseases such as systemic lupus erythematosus. Learn about the Academy's advocacy priorities and how to join efforts to protect your practice. Epub 2020 Aug 3. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. Critically ill patients in ICUs have developed multi-organ thrombotic events, leading to questions of empiric anticoagulation in some patients with COVID-19. PCR testing was not available for the other 3 antibody-positive patients. J Eur Acad Dermatol Venereol. Accessibility Oral lesions. The site is secure. 1). As someone who cares for patients with sarcoidosis, I am used to "pernio" (lupus pernio) suggesting a different prognosis than other skin manifestations (in sarcoidosis, of course, lupus pernio implies more severe, chronic disease!). As the global crisis has mushroomed, the international dermatological community has started to report relevant observations regarding the cutaneous manifestations of this affliction. As expected, a viral type exanthem may be noted; additionally, acral pernio-like lesions, livedo reticularis, urticaria, petechial, and vesicular rashes have all been described. Careers, Unable to load your collection due to an error. (2), In their commentary about Recalcatis article, Su and Lee questioned whether the three patterns described (erythematous, urticarial, and varicelliform) are specific to the coronavirus. The https:// ensures that you are connecting to the Advertising on our site helps support our mission. The occasional appearance of livedo reticularislike manifestations on the lower limbs was also referred. Of the 20 patients known to have antibody testing (IgM, IgG, unspecified, or both), only 6 (30%) tested positive. The rash lasted 20 minutes. Viral kinetics and antibody responses in patients with COVID-19 [preprint]. 2022 Dec 13;13(12):2355. doi: 10.3390/genes13122355. Clinical characteristics of patients with confirmed and suspected COVID-19 who developed pernio-like lesions on acral skin. Bethesda, MD 20894, Web Policies The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). . Multiple reports of cutaneous manifestations of the virus have been described, including a pernio-like eruption, recently termed "COVID toes." Federal government websites often end in .gov or .mil. For 42 patients with the full course of pernio observed by providers, the lesions lasted for a median of 14days (interquartile range, 10-21days). 2020. Epub 2022 Nov 7. For this subanalysis, we included patients with new-onset pernio-like skin changes in the setting of confirmed or suspected COVID-19 and excluded patients with prior history of pernio. 10. official website and that any information you provide is encrypted The weather in North America has been cooler this spring in parts of Canada and small regions of North America (though March overall was another record-warm month), due partially to an abnormal jet stream as a result of climate change. A cross-sectional study of nearly 900 patients with COVID-19 found a significantly higher prevalence of HSV-1 and VZV than in the hospital population, even when adjustments were made for numerous comorbidities. Urticaria is also common in COVID-19. Magro C., Mulvey J.J., Berlin D. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. More than 40 million people have been infected with the severe acute respiratory syndrome coronavirus 2 since the first infection was reported in December 2019 from Wuhan, China. and therefore, a correlation between COVID19 infection and this cutaneous eruption has been hypothesized. Finally, reliable testing combined with coordination of timing of these skin changes with COVID-19 PCR, IgG, andIgM testing results is imperative to better establish self-isolation recommendations for patients presenting with pernio-like lesions. 2020;183:7177. As experience with caring for patients with COVID-19 has accumulated since the onset of the pandemic, so has our understanding of its associated cutaneous manifestations and their clinical implications. Manalo et al presented two cases of unilateral transient livedo reticularis (LR) in COVID-19 patients. J Am Acad Dermatol 2020; Mar 22 pii: S0190-9622(20)30454-0. doi: 10.1016/j.jaad.2020.03.036. This case, together with those already reported in the literature, raises the question of whether the vaccineelicited immune response could be involved in the development of perniolike manifestations, as it has been described following COVID19 infection. 8600 Rockville Pike Diagnose it (@diagnose_it) on Instagram: "COVID toes @diagnose_it . COVID toes . Notably, 29% of patients lived in geographic regions with average March 2020 temperatures above 10C, temperatures at which idiopathic pernio is less likely. Laboratory tests (complete blood count, antinuclear antibodies, antiphospholipid antibodies, Creactive protein, erythrocyte sedimentation rate, serum protein electrophoresis and serum cryoglobulins) were normal, excluding the presence of concomitant systemic diseases. In addition, there may be confirmation bias in reporting. Epub 2020 Aug 9. -, Manalo I.F., Smith M.K., Cheeley J., Jacobs R. A dermatologic manifestation of COVID-19: transient livedo reticularis. Perniolike lesions on the fingers of right hand after the second dose of PfizerBioNTech vaccine. Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Takeshita J, French LE, Thiers BH, Hruza GJ, Fox LP; American Academy of Dermatology Ad Hoc Task Force on COVID-19. Physical examination showed erythematousviolaceous patches and swelling on the fingers, accompanied by itching and burning sensation (Fig. Limitations: In addition, the levels of some T cell-derived cytokines, such as IL-17, are increased in the context of SARS-CoV-2 infection In some patients with COVID-19, a cytokine storm develops that resembles secondary haemophagocytic lymphohistiocytosis, a hyperinflammatory state triggered by viral infections. (10). J Eur Acad Dermatol Venereol 2020 Apr 15 doi: 10.1111/jdv.16469. J Am Acad Dermatol. J Am Acad Dermatol. Accessibility Advertising on our site helps support our mission. PMC Methods: The target population was individuals with suspected or laboratory-confirmed COVID-19 with pernio-like lesions. [Epub ahead of print], Magro C, Mulvey JJ, Berlin D, et al. eCollection 2022. 2020 Oct;83(4):1118-1129. doi: 10.1016/j.jaad.2020.06.1016. Indeed, interferon response to viral infection appears to be a clue why some patients do poorly while others fare well.12 Pernio-like skin lesions associated with COVID-19: A case series of 318 patients from 8 countries. Learn to map out your practices future, build skills with popular hands-on courses, and tackle day-to-day challenges of practice management. The 2 IgM-positive and IgG-negative antibody-confirmed patients both tested negative by PCR. Piccolo V., Neri I., Filippeschi C. Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients. COVID-19 and cutaneous manifestations: A review of the published literature. But the diffuse pattern may be more common. Pernio-like lesions lasted a median of 14days (interquartile range, 10-21days). It is hard to fathom that Part I of this series was published just a month ago. Italy. (4) In a final reply, Estbanez et al reported the case of a 28-year-old woman who presented with cough, fatigue, and other symptoms, was found to be coronavirus-positive. An official website of the United States government. The other 2 of 6 patients with suspected COVID-19 with histopathology reported vascular changes, including lymphocytic vasculitis, which can sometimes be seen in conjunction with variants of pernio. Disclaimer. Patients were generally young and healthy, with median age of 25years (interquartile range, 17-38years), including 93 children and adolescents. 2020. Additionally, they advocated further studies to determine the dynamic viral load and viremia at different points in the rash (prior, during, and after). This large international registry-based case series adds to the emerging evidence that pernio-like lesions may be a cutaneous manifestation of COVID-19. We documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions. 4 We would like to thank the American Academy of Dermatology Ad Hoc Task Force on COVID-19 and staff at the American Academy of Dermatology for their logistical and administrative support. COVID toes is a condition that causes swelling and discoloration of a person's toes and fingers. 2021 May-Jun;39 (3):380-383. doi: 10.1016/j.clindermatol.2021.01.016. Emerging evidencesuggests that coronavirus infectious disease 2019 (COVID-19) has associated dermatologic manifestations. Patients generally had mild COVID-19 clinical courses, with 6 patients hospitalized, 2 of whom died.